Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to assess the risk for entrapment, review the risks and benefits, and obtain informed consent for the use of side rails for one resident. The facility's policy requires a side rail assessment to be completed in the electronic medical record, alternatives to be attempted prior to side rail use, and informed consent to be obtained from the resident or their representative if the rail meets the definition of a restraint. However, for a resident with diagnoses including orthopedic after care, vascular dementia, insomnia, use of anticoagulants, weakness, reduced mobility, and rheumatoid arthritis, these steps were not followed. The resident, who had moderately impaired cognition and an activated Power of Attorney (POA), was observed with side rails on their bed. Upon review of the medical record, there was no documentation of a side rail assessment or consent from the POA. The Nursing Home Administrator confirmed that the required assessment and consent were not present for this resident.