Failure to Monitor Bed Rail Use According to Policy
Penalty
Summary
The facility failed to ensure ongoing monitoring of bed rail use for three residents who were reviewed for accident hazards. Observations showed that these residents had bilateral bed rails in use, despite their Minimum Data Set (MDS) assessments indicating that bed rails were not in use. Physician orders and care plans were present for bed rail use, but there was no documentation of ongoing monitoring or quarterly evaluations as required by facility policy. The policy specified that evaluation for bed rail use should be completed at least quarterly and with any change of condition. Record reviews for each resident confirmed the absence of documentation regarding ongoing monitoring of bed rail use. During an interview, the Director of Nursing acknowledged that the required quarterly evaluations for bed rail use had not been completed. This lack of monitoring was identified through observation, record review, and staff interview, and was cited as a failure to meet professional standards of practice.