Failure to Assess, Document, and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to properly assess, document, and obtain informed consent for the use of bed rails and grab bars for two residents. For one resident with a history of stroke, dysphagia, and moderate cognitive impairment, grab bars were installed after a fall at the request of the resident and family. However, there was no evidence of a physician's order, a completed side rail assessment, informed consent, or a care plan addressing the use of bed rails or grab bars for mobility. The resident's care plan only addressed fall risk with interventions such as floor mats and a high back wheelchair, but did not mention bed rails or grab bars. For another resident with severe cognitive impairment, pressure ulcer, and significant mobility needs, grab bars were observed in use despite the comprehensive assessment indicating no bed rail use. While there was a physician's order for quarter side rails to enable bed mobility, there was no documented side rail assessment, informed consent, or care plan addressing the use of bed rails or grab bars for mobility. The care plan focused on combative behavior and risk of injury during care, but did not include interventions related to bed rails or grab bars. Interviews with nursing staff and administration revealed a lack of awareness and inconsistent practices regarding the assessment, documentation, and consent process for bed rail use. The facility's policy required assessment, physician's order, informed consent, and care plan development for bed rail use, but these steps were not followed for the two residents. The absence of these required processes was confirmed through record review, staff interviews, and direct observation.