Failure to Obtain Assessment, Consent, and Physician Order for Bed Rail Use
Penalty
Summary
The facility failed to obtain required evaluation assessments, consents, and physician's orders for the use of bed rails for two residents. According to the facility's policy, any resident considered for bed rail use must be evaluated by the interdisciplinary team to determine appropriateness, and if deemed suitable, the facility must educate the resident or representative on risks, obtain documented consent, notify the representative as appropriate, and secure a specific physician's order detailing the type and use of bed rails. For both residents sampled, there was no evidence in the electronic health records of an evaluation assessment, consent, or physician's order related to the use of bed rails. One resident, who was severely cognitively impaired, was repeatedly observed with quarter length bed rails in use on various days, with no documentation of the required assessment, consent, or order. Another resident, who was alert and oriented, was also observed with a one-third length bed rail in use on multiple occasions, again without the necessary documentation. Staff interviews confirmed that the expected procedures were not followed for these residents, and the required documentation was missing.