Failure to Conduct Ongoing Bedrail Assessments
Penalty
Summary
The facility failed to conduct ongoing assessments to ensure that bedrails were used appropriately and that risks associated with their use were continually evaluated for a resident with dementia. Observations on two separate days confirmed that the resident's bed was equipped with bilateral enabler bars. The resident's clinical record indicated a diagnosis of dementia and an MDS assessment showed the resident was rarely or never understood, highlighting significant cognitive impairment. A physician's order for the enabler bars was present, and informed consent had been obtained from the resident's responsible party. However, after the initial assessment and consent in January 2024, there was no further documentation of ongoing monitoring or reassessment of the resident's need for bedrails or evaluation of associated risks. Facility documentation referenced a policy of ongoing monitoring and adjustment, but no evidence was found to support that this was carried out for the resident in question. The Nursing Home Administrator confirmed that no additional documentation existed to demonstrate ongoing assessment or monitoring of the bedrail use for this resident.