Failure to Assess and Attempt Alternatives Prior to Bedrail Use
Penalty
Summary
Facility staff failed to assess and attempt alternatives prior to the use of bedrails for one resident. The resident, who had a history of right above the knee amputation, atherosclerosis, diabetes, and chronic kidney disease, was cognitively intact and required varying levels of assistance with self-care activities. Despite these needs, there was no documentation in the clinical record of any alternatives being tried before bedrails were implemented, nor was there evidence of a bedrail assessment. Observations showed the resident with bilateral bedrails in use on multiple occasions, both while in bed and seated at the bedside. During an interview, the resident expressed a preference for bedrails but could not recall requesting them or being informed of their risks and benefits. The record review confirmed the absence of documentation regarding alternatives, their effectiveness, or informed consent. Facility leadership did not provide comments or concerns when interviewed about these findings.