Failure to Attempt Alternatives Prior to Bed Rail Installation
Penalty
Summary
The facility failed to attempt alternative interventions prior to the installation of side rails for two residents who were assessed for side rail use. Both residents had a history of hemiplegia and hemiparesis following a stroke, resulting in significant physical impairment and severe cognitive impairment. Documentation for both residents included a Device and Bed Rail Review, but these assessments did not include any questions or evidence regarding the use of alternatives before side rails were implemented. Care plans for both residents focused on the use of quarter length side rails to enable bed mobility and noted the increased risk for complications, but did not document any trial of less restrictive measures. Observations confirmed that both residents were using side rails during the survey period. Interviews with the nurse responsible for the assessments, as well as with the DON and Administrator, revealed that alternative interventions were not attempted prior to the installation of side rails. Staff indicated they were unaware that trying alternatives was a requirement before implementing side rails for these residents.