Failure to Offer and Document Alternatives Prior to Bed Rail Use
Penalty
Summary
The facility failed to ensure that alternatives to bed rails, such as small grab bars or positioning devices, were offered, attempted, and documented in the medical record prior to the use of bilateral half side rails for four residents. For each resident observed with side rails, there was no evidence in their medical records that less restrictive alternatives were considered or trialed before the installation of the rails. Documentation, including consent forms and assessments, was incomplete or lacked details regarding the exploration of alternatives. One resident, who had a history of heart failure, obesity, and diabetes, was admitted from the emergency department and assessed as not needing restraints. However, she was observed with bilateral half side rails, and both the resident and staff confirmed that no alternatives were discussed or offered prior to installation. The consent form was signed by the resident but not by staff, and it did not document any alternatives considered. Similar deficiencies were found for other residents, including those with intact cognition and those requiring assistance with mobility, where bed rails were installed without documented evidence of alternative devices being offered or attempted. Interviews with staff, including nursing assistants, the DON, and maintenance personnel, revealed a lack of awareness or process for considering alternatives to side rails. Staff indicated that bed rails were routinely used and often came with the beds, and there was no established practice of evaluating or offering other devices. Facility policy required less restrictive interventions to be considered and documented prior to side rail use, but this was not reflected in the records or staff actions for the residents involved.