Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to assess a resident for risk of entrapment from bed rails prior to their installation and did not review the risks and benefits of bed rails with the resident or the resident's representative, nor did it obtain informed consent before installation. Specifically, a cognitively intact female resident with a history of right femur fracture, hypertension, heart disease, and weakness was admitted and had physician orders for quarter bed rails to assist with mobility. The care plan included the use of side rails for safety and mobility, with instructions to observe for injury or entrapment and reposition as needed. However, there was no evidence in the resident's electronic medical chart of a completed bed rail assessment or signed consent for bed rail use. Observations confirmed the presence of bed rails on both sides of the resident's bed, and interviews with the resident and her representative revealed that the representative did not recall signing a consent form. Facility staff, including the ADON and ADMN, acknowledged that assessments and consents should have been completed and documented prior to bed rail installation, as required by facility policy. The failure to complete these steps was attributed to turnover in the DON position.