Failure to Obtain Assessment, Consent, and Physician Order Prior to Bedrail Use
Penalty
Summary
The facility failed to follow its own policy and regulatory requirements regarding the use of bed rails for a resident. Specifically, the facility did not ensure that a physician's order, informed consent, or a comprehensive assessment was obtained prior to the application of bilateral upper bedrails. The resident was observed with the bedrails elevated, and staff confirmed that the bedrails were being used to prevent falls. However, a review of the resident's medical record showed no documentation of an assessment for safety risks, no evidence that alternatives to bedrails were attempted, and no record of informed consent being obtained from the resident's representative, despite the resident lacking capacity to make decisions. Additionally, the facility did not initiate a care plan to address the use of bedrails for this resident. The facility's policy requires that alternatives be attempted, risks and benefits reviewed, and informed consent obtained before bedrails are used, but these steps were not documented or completed. The DON and Administrator acknowledged that the required documentation and processes were not present in the resident's record.