Failure to Assess and Use Alternatives Prior to Bed Rail Installation
Penalty
Summary
The facility failed to use appropriate alternatives before installing bed rails and did not assess each resident for the risk of entrapment prior to installation. Observations revealed that all beds, both occupied and unoccupied, had bed rails installed, with four different types of bed rails in use throughout the unit. The Maintenance Director confirmed that beds are not inspected prior to new admissions and there is no policy for inspecting bed rails. The Director of Nursing stated that all residents have bed rails because the bed controls are on them and acknowledged the use of various types of beds and rails, with no knowledge of the manufacturer's guidelines. Record review showed that side rail assessments and consents were only completed upon admission, with no ongoing assessments or documentation of entrapment risk. The MDS Registered Nurse confirmed that assessments are only done at admission and that the current assessment form does not address entrapment risk. No further information or documentation regarding bed rail safety or manufacturer guidelines was provided by the end of the survey.