Failure to Complete Bed Rail Assessments and Obtain Informed Consent
Penalty
Summary
The facility failed to assess the risks of entrapment and complete bed rail assessments, as well as failed to obtain informed consent prior to the installation of bed rails for two residents. For one resident with dementia and Parkinson's disease, there was no documentation of a bed rail assessment since admission, despite the resident having severely impaired cognition and being dependent on staff for bed mobility. Observations showed the resident using bilateral quarter-length bed rails with staff assistance, and interviews with staff confirmed that bed rail assessments and informed consent from the responsible party had not been completed. Another resident with a non-displaced fracture and osteoporosis, who was her own responsible party, also had no bed rail assessment documented since admission. This resident had moderately impaired cognition and required substantial assistance for bed mobility, but was observed to be ambulatory and able to stand without assistance. Staff interviews indicated that bed rail assessments were supposed to be completed upon admission and quarterly, and that consent was required for residents with impaired cognition, but these steps had not been followed. Interviews with the Rehab Therapy Director, DON, and Regional Clinical Director of Operations revealed a lack of a clear process and communication regarding responsibility for bed rail assessments. It was acknowledged by leadership that assessments should be completed prior to bed rail installation, upon admission, and quarterly, but this was not occurring in practice. Maintenance was also expected to ensure proper installation and fit of bed rails, but the required assessments and consents were not documented for the residents involved.