Failure to Inform Resident or Representative About Bed Positioning Risks and Benefits
Penalty
Summary
A deficiency occurred when the facility failed to inform a resident and/or their representative about the risks and benefits of positioning the resident's bed against the wall. The facility's policy requires that residents be fully informed of their health status and any changes in care or treatment, but review of the electronic health record (EHR) showed no evidence that the resident was assessed, evaluated, or informed regarding the bed's position. The resident in question had severe cognitive impairment, was unable to walk, and had limited range of motion in both lower legs. Multiple observations confirmed the bed was positioned against the wall on several occasions. Interviews with facility staff, including registered nurses and the Director of Nursing, revealed that there was no physician order for the bed's position and no documentation that the resident or their representative had been informed or involved in the decision. Staff acknowledged that the expected process of assessment, evaluation, and communication regarding the bed's position had not occurred for this resident.