Failure to Assess, Obtain Orders, and Care Plan for Side Rail Use
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and multiple medical conditions, including end stage renal disease, dependence on renal dialysis, gastrostomy feeding, difficulty walking, and muscle weakness, was observed in bed with a padded full side rail in place. The resident was restless and appeared to be attempting to get out of bed, with the side rail preventing a fall. The bed was in the lowest position and a floormat was placed on the floor, but there was no documentation or evidence of appropriate assessment or authorization for the use of the side rail. Review of the resident's electronic medical record revealed the absence of a care plan addressing the use of side rails, no mention of side rails in the fall prevention care plan, and no informed consent or assessment for side rail use. Additionally, there were no initial entrapment measurements or grids for the bed/side rails, and no physician orders authorizing the use of side rails. Interviews with facility staff, including the DON and Unit Manager, confirmed that these required steps were not completed for this resident. Facility policy requires that side rails, considered a form of physical restraint when they restrict movement and cannot be easily removed by the resident, must only be used after a written physician order, informed consent, and a thorough assessment. The policy also mandates documentation of the medical reason for side rail use, compatibility checks, entrapment measurements, and inclusion in the resident's care plan. None of these procedures were followed for the resident in question, resulting in the cited deficiency.