Failure to Ensure Proper Assessment and Documentation for Bed Rail Use
Penalty
Summary
The facility failed to ensure proper assessment, documentation, and care planning regarding the use of bed rails for four residents. For one resident, although informed consent from the responsible party and a physician's order for side rails as an enabler were documented on one occasion, there was no current physician's order in the medical record for the use of bilateral half side rails, nor was there a care plan intervention addressing their use. Observations confirmed that the resident's bed had the side rails elevated, and both the RN and DON verified the absence of the required order and care plan. For two other residents, the facility did not document that less restrictive alternatives were attempted prior to the use of bilateral half side rails. Both residents were observed using the side rails and reported using them to assist with turning in bed. While physician's orders for the use of side rails as enablers were present, the Bed Safety Rail assessments did not show evidence that alternatives such as roll guards, foam bumpers, or lowering the bed were tried before implementing side rails, as required by facility policy. Another resident was observed with bilateral half side rails elevated and reported using them for turning, but required staff assistance for safety. The medical record review showed no documented evidence of a physician's order or informed consent for the use of side rails, and no care plan was initiated to address their use. Staff interviews confirmed that the required steps, including attempting less restrictive alternatives, obtaining physician's orders, and informed consent, were not completed for these residents prior to the use of side rails.