Failure to Obtain Orders, Consent, and Assessments for Bed Rail Use
Penalty
Summary
Surveyors identified that the facility failed to follow required protocols for the use of bed side rails for multiple residents. Observations revealed that several residents were found in bed with elevated bilateral side rails without evidence of a physician's order, informed consent, or proper assessments documented in their medical records. In several cases, residents had cognitive impairments or lacked capacity to make decisions, yet there was no documentation of family or representative involvement in the consent process. Staff interviews confirmed that the necessary steps, such as obtaining a physician's order, conducting entrapment and bed rail assessments, and securing informed consent, were not consistently completed prior to the application of side rails. Medical record reviews for the affected residents showed missing or incomplete documentation, including absent physician orders for side rail use, lack of informed consent forms, and incomplete interdisciplinary team (IDT) evaluations. In some instances, side rail evaluations indicated that side rails were not indicated for the resident, yet the rails were still in use. Additionally, some residents' records lacked documentation of the risks and benefits discussion or the rationale for side rail use, and in certain cases, the IDT meeting documentation was incomplete or missing required signatures from care team members such as the physician or social worker. The facility's own policies and procedures require that alternatives to bed rails be attempted first, and if unsuccessful, a comprehensive assessment, interdisciplinary evaluation, and informed consent must be completed before side rails are used. Despite these requirements, the facility failed to ensure compliance, resulting in the use of side rails without proper authorization or assessment for nine sampled residents and one non-sampled resident. These failures were confirmed through staff interviews and record reviews, and were found to be inconsistent with both facility policy and federal safety alerts regarding the risks of bed rail entrapment.