Failure to Obtain Informed Consent and Complete Bed Rail Safety Assessments
Penalty
Summary
The facility failed to obtain informed consent for the use of side rails or enabler bars for two out of three residents reviewed, and did not assess entrapment risk for two out of three residents. For one resident with generalized muscle weakness and difficulty walking, a side rail was observed in use, but there was no documentation of informed consent or an entrapment risk assessment. The resident's family had brought and attached the side rail to the bed after admission, but the facility did not complete the required assessments or obtain consent. Interviews with facility leadership confirmed the absence of these documents. Another resident with generalized muscle weakness and mobility issues was observed using an enabler bar, but there was no evidence of informed consent in the clinical record, despite staff documentation indicating otherwise. For a third resident, enabler bars were present on both sides of the bed, and while bed safety assessments were performed periodically, the assessment for one entrapment zone (Zone 6) was consistently left incomplete. These findings were confirmed through interviews and record reviews, indicating lapses in both documentation and assessment procedures related to bed rail and enabler bar use.