Failure to Assess and Document Side Rail Use Prior to Implementation
Penalty
Summary
The facility failed to follow required procedures before the use of bilateral quarter length side rails for a resident with Alzheimer's disease and non-Alzheimer's dementia. The resident, who required partial to moderate assistance with bed mobility and was moderately cognitively impaired, was observed on two occasions with both side rails raised. There was no evidence in the resident's electronic medical record that alternative interventions were attempted prior to the use of side rails, nor was there documentation of a side rail assessment, entrapment risk evaluation, or a review of risks and benefits with the resident or their representative. Informed consent for the use of side rails was also not obtained. Interviews with facility staff revealed a lack of clarity regarding responsibility for completing side rail assessments. The nurse interviewed stated she did not perform side rail assessments and was unsure who was responsible. The DON indicated that assessments were only completed if side rails appeared necessary for positioning and mobility, and was unaware that alternatives needed to be attempted and documented. The Administrator confirmed that side rail assessments were not completed on admission or quarterly for the resident in question.