Failure to Assess, Obtain Consent, and Attempt Alternatives Before Bed Rail Use
Penalty
Summary
The facility failed to follow its own policy and regulatory requirements regarding the use of bed rails for three residents. Specifically, staff did not attempt appropriate alternatives before installing bed rails, did not assess the residents for safety risks or risk of entrapment, did not review the risks and benefits with the residents or their representatives, and did not obtain informed consent prior to installation. These failures were identified through observation, interviews, and record reviews for three residents with severe cognitive impairments and multiple medical diagnoses, including dementia, Alzheimer's disease, and communication deficits. For one resident, documentation showed the use of half rails for bed mobility and transfers, but there was no physician order, no assessment for side rail use, and no informed consent on file. The resident's representative was unaware of the bed rail installation and had not been consulted. Another resident was observed with half rails up on both sides of the bed, but there was no mention of bed rails in the care plan, no physician order, no assessment, and no informed consent documented. A third resident, also with severe cognitive impairment, had half rails in use for bed mobility and transferring, but again, there was no physician order, no assessment for entrapment risk, and no informed consent obtained. Interviews with staff revealed inconsistent understanding and application of the facility's bed rail policy. Some staff believed that consent was only needed in certain situations or that the signed restraint policy in the admission packet was sufficient. Others were unsure of the policy or relied on charge nurses to ensure proper documentation. The facility's policy required alternatives to be attempted, interdisciplinary evaluation, resident assessment, and informed consent before bed rail use, but these steps were not followed for the residents reviewed.