Failure to Assess and Attempt Alternatives Prior to Bed Rail Use
Penalty
Summary
The facility failed to comprehensively assess and attempt alternatives prior to the use of bed rails for two residents who were observed to have grab bars installed on their beds. Both residents were cognitively intact and had varying degrees of independence with activities of daily living, but their care plans did not identify the presence of grab bars. Documentation in their medical records lacked a comprehensive assessment regarding the appropriate use of bed rails, safety measurements, and any attempted alternatives before the installation of the bed rails. Observations revealed that both residents had double-sized standard beds with black grab bars attached, which were used to assist with positioning and transfers. Interviews with the residents indicated that the grab bars were either brought in by family members or were present when the residents arrived at the facility. Neither resident was aware of any staff assessment of the grab bars. Staff interviews confirmed that the usual practice was to obtain a consent form for bed rail use and review it annually, but staff were not aware of any alternatives being tried prior to installation. The acting DON confirmed that the facility had not completed assessments of the grab bars and did not have the manufacturer's instructions for the devices in use. The facility's policy required a person-centered approach, including the assessment of alternatives, evaluation of risks such as entrapment, and assurance of correct installation and maintenance. However, these steps were not documented or completed for the two residents, resulting in a deficiency related to the use of bed rails without comprehensive assessment and consideration of alternatives.