Failure to Assess and Document Bed Rail Use as a Restraint
Penalty
Summary
The facility failed to perform and document a complete assessment for the use of bed rails as a restraint for one resident. Observations showed the resident had bed rails in the up position on both sides of the bed and was unable to lower the rail independently due to left-sided paralysis and limited hand mobility following a stroke. The resident reported using the bed rails frequently and stated they prevented him from getting out of bed. Staff interviews confirmed that the resident was assessed and the use of bed rails was discussed, but the documentation did not reflect that the bed rails functioned as a restraint, nor did it indicate that the resident could not remove them independently. Review of the resident's records showed physician orders for bed rails for mobility, but the Assistive Device/Restraint Initial Evaluation did not identify the bed rails as a restraint or document that they limited the resident's movement. The facility's policy defined a restraint as any device the resident cannot remove easily, which restricts freedom of movement, and specified that the definition is based on the resident's functional status. The assessment failed to address these criteria, resulting in incomplete documentation and assessment for the use of bed rails as a restraint.