Failure to Follow Bed Rail Assessment and Consent Procedures
Penalty
Summary
The facility failed to follow its own policy and regulatory requirements regarding the use of bed rails for six residents. Observations revealed that multiple residents were using partial bed rails on their beds, and interviews with staff confirmed that these bed rails had been installed without proper documentation or assessment. Specifically, there was no evidence that alternatives to bed rails were attempted prior to their use, nor was there documentation of informed consent from the residents or their representatives. Additionally, the required assessment of risks and benefits, including the risk of entrapment, was not completed or documented before the installation of bed rails. Clinical record reviews for the affected residents showed that none had documentation supporting the necessary steps for bed rail use. This included the absence of a bed rail assessment, lack of documentation of alternatives attempted, no record of risk versus benefit discussions, and no informed consent obtained. The residents involved had varying levels of cognitive function, as indicated by their BIMS scores, with some having intact cognition and others having severe cognitive impairment. Despite these differences, the facility did not individualize or document the decision-making process for bed rail use as required by policy. Interviews with nursing staff confirmed the lack of documentation and adherence to policy for all residents observed with bed rails. The facility's policy clearly states that the interdisciplinary team must assess the resident, attempt alternatives, review risks and benefits, obtain informed consent, and assess for entrapment risk prior to bed rail installation. These steps were not followed or documented for the six residents identified, resulting in a failure to ensure that residents and their representatives were fully informed and protected according to facility policy and regulatory standards.