Failure to Follow Bed Rail and Restraint Policies for Multiple Residents
Penalty
Summary
The facility failed to follow its own policies and procedures regarding the use of bed rails and physical restraints for four residents. For one resident with severe cognitive impairment and total dependence for activities of daily living, staff installed bilateral upper half side rails without obtaining informed consent from the resident or their responsible party. Both the LVN and DON confirmed that no signed informed consent was present in the resident's chart or electronic medical record, despite facility policy requiring this before side rail use. Another resident, who was cognitively intact and independent in bed mobility, had bilateral side rails with damaged and ripped padding. The resident stated they did not use or want the side rails, and there was no documentation that alternative interventions had been attempted prior to their use. The DON acknowledged the lack of clinical documentation for attempted alternatives and agreed that the damaged padding should have been replaced to ensure safety and dignity, as required by facility policy. Two additional residents with seizure disorders and physician orders for padded side rails were observed to have bedside rails without any foam padding. Both residents had documented cognitive impairment and active orders for padded rails as a safety precaution. Staff interviews confirmed that the required padding was not present, and the DON stated that padding was necessary to prevent injury during seizures. Facility policy specified that side rails should be padded if ordered by a physician for seizure management.