Failure to Complete Bedrail Assessment and Obtain Consent Prior to Grab Bar Use
Penalty
Summary
The facility failed to ensure that alternatives were attempted, a risk assessment was conducted, and informed consent was obtained prior to the use of bilateral grab bars on the bed for a resident with dementia and severe cognitive impairment. The resident, who had functional limitations in her upper and lower extremities and required substantial assistance with bed mobility and transfers, was observed to have grab bars installed on both sides of her bed. The care plan noted the use of grab bars to maintain independence with bed mobility and acknowledged the increased risk for complications, but there was no documentation in the medical record of attempted alternatives, a Device/Bedrail assessment, or informed consent for the use of the grab bars. Interviews with facility staff, including the current and previous DONs, confirmed that the required assessments and consents were not completed or documented for this resident. The DON stated that the facility's process required a risk assessment and informed consent prior to the use of grab bars, and that these should be documented in the resident's record. However, upon review, neither the assessment nor the consent could be found. Staff interviews further confirmed that the grab bars had been in use for an extended period without the necessary documentation or reassessment.