Failure to Assess and Document Alternatives Prior to Bed Rail Use
Penalty
Summary
The facility failed to follow required procedures before installing and using bilateral quarter length side rails for three residents. Specifically, staff did not attempt or document alternative interventions prior to the installation of side rails, did not assess for entrapment risk, and did not review the risks and benefits of side rail use with the residents or their representatives. Informed consent was also not obtained before the side rails were put in place. These failures were identified through observations, record reviews, and staff interviews. For one resident with dementia, arthritis, and heart failure, the Minimum Data Set (MDS) indicated moderate cognitive impairment and a need for assistance with bed mobility. The care plan did not address side rail use, and the bed side rail assessment tool was incorrectly completed, indicating no side rails were used. The admission nurse and DON confirmed that the assessment was inaccurate and that required steps such as risk/benefit review, consent, and entrapment risk evaluation were not performed. The resident was observed using the side rails, and both the DON and Administrator acknowledged the documentation errors and lack of awareness regarding the need for alternative interventions. Similar deficiencies were found for two other residents: one with an acquired loss of a limb and another with multiple medical conditions including diabetes and muscle wasting. In both cases, the bed side rail assessment tools were incomplete, lacking documentation of alternative interventions, entrapment risk assessment, and consent. Staff interviews revealed a lack of knowledge about the requirement to try and document alternative interventions before side rail installation. Observations confirmed that both residents were using side rails, and neither the DON nor the Administrator was aware of the procedural requirements that had been missed.