Failure to Obtain Orders and Consents for Bed Rail Use
Penalty
Summary
The facility failed to obtain required physician orders, informed consents, and signed statements of understanding for the use of bed rails for five of thirteen sampled residents. Observations revealed that bed rails or similar devices were present on both sides of the beds for these residents, yet their electronic medical records did not contain the necessary documentation authorizing their use. Care plans referenced the use of bed canes, assist rails, or quarter rails to aid in bed mobility, repositioning, or transfers, but there was no evidence of proper assessment, consent, or physician order for these devices. Interviews with staff indicated confusion regarding the terminology and processes for bed rail use. Some staff members acknowledged that both physician orders and consents were required, while others were uncertain about the need for consents. Staff also reported inconsistent practices, such as sometimes obtaining paper consents or entering orders after assessments, but not consistently ensuring all required documentation was completed. There was also a lack of clarity among staff about the distinction between bed rails and bed canes, with some believing that consents were not needed for bed canes, despite their functional similarity to bed rails. A review of facility documents showed that there was a form intended for side rail utilization assessment and a policy requiring consent after presenting risks and benefits, but these were not consistently implemented. No additional documentation for physician orders, consents, or statements of understanding was provided for the affected residents during the survey. The lack of a standardized process and consistent terminology contributed to the failure to comply with requirements for the safe and authorized use of bed rails.