Failure to Assess Alternatives and Entrapment Risk Before Side Rail Use
Penalty
Summary
The facility failed to ensure that alternative measures were attempted prior to the installation of side rails and did not complete a proper assessment for the risk of entrapment for a resident with intellectual disabilities. Record review showed that the resident was admitted with intellectual disabilities and had a care plan intervention for bilateral side rails at the request of the family. However, there was no physician order for side rail use, and documentation did not show that alternatives to side rails were explored or that an entrapment risk assessment was completed. Observations confirmed that the resident was in bed with full side rails up on both sides. Interviews with the MDS Coordinator and the DON revealed that the facility was not exploring alternatives before using side rails and was not assessing for entrapment risk. The staff stated they were unaware of these requirements, and the only actions taken were a side rail assessment and obtaining signed consent, without considering or documenting alternative interventions or entrapment risk.