Failure to Ensure Appropriate Use and Monitoring of Bed Rails
Penalty
Summary
Surveyors identified that the facility failed to ensure appropriate use and ongoing monitoring of bed rails for three out of seven residents reviewed. The facility's policy required assessment by physical therapy, physician orders, informed consent, proper installation, care plan updates, and reassessment every six months. However, documentation and observations revealed that these steps were not consistently followed. For example, one resident had a left bed enabler for assistance with positioning, but subsequent assessments showed the resident was fully dependent on staff for all activities of daily living (ADLs) and required a Hoyer lift, with no evidence that the continued use of the bed rail was reviewed for appropriateness. Another resident had a right side bed enabler ordered for assistance with turning and repositioning, but was documented as dependent for bed mobility and required two staff for rolling in bed. During care, the resident was unable to use the bed rail due to a contracted hand, and staff confirmed the resident's dependence for turning. A third resident had a physician's order for a single bed rail, but was observed with bilateral bed rails in use. This resident also required two staff for turning and repositioning, and was unable to use one of the bed rails as intended during care. Additionally, the facility lacked evidence of preventive maintenance or safety checks for the bed rails in use. Staff confirmed that there was no documentation of such checks, despite the manufacturer's guidelines being available. These findings indicate that the facility did not ensure bed rails were used according to policy and did not maintain ongoing safety monitoring for residents using bed rails.