Failure to Obtain Physician Order and Informed Consent for Siderail Use
Penalty
Summary
The facility failed to obtain a physician's order and informed consent prior to the installation of bilateral one-fourth siderails/bedrails for a resident. The resident, who had diagnoses including hemiplegia, hemiparesis, and diabetes mellitus, was severely cognitively impaired and dependent on staff for all activities of daily living. During observation, the resident was found in bed with both siderails up, and review of the medical record confirmed that neither a physician's order nor informed consent had been documented before the siderails were installed. Interviews with facility staff, including the Minimum Data Set Coordinator and the Assistant Director of Nursing, confirmed that the required physician's order and informed consent were missing. The facility's policies and procedures specify that informed consent and a physician's order are necessary before siderails are used, especially when they may function as a physical restraint. The absence of these steps placed the resident at risk for entrapment and injury associated with siderail use.