Failure to Assess Bed Rail Safety and Obtain Consent
Penalty
Summary
The facility failed to ensure that residents were properly assessed for the safety risks associated with bed rail use, specifically the risk of entrapment, for two out of three residents reviewed for accidents. For one resident, staff completed a bed rail assessment in January, but did not reassess after a significant change in condition in July, despite the resident experiencing several falls and a decline in mobility. Observations confirmed the presence of bed rails and a fall mat, and interviews with staff revealed that the resident was unaware of the risks of getting up unassisted and that bed rails were used as a fall prevention measure. However, no updated assessment was documented following the change in the resident's condition. For another resident, bed rails were in use as ordered by a physician to assist with mobility and independence, but there was no documentation of a side rail assessment in the medical record. Progress notes did not mention the use of side rails, and the care plan referenced their use without evidence of a prior safety assessment. Interviews with staff indicated that consents for bed rails were routinely obtained upon admission, but assessments for bed rail safety were not completed prior to their placement. The interdisciplinary team confirmed that residents should be assessed for bed rail safety before and after placement, especially following changes in condition, but acknowledged that these assessments and consents were not consistently documented or obtained.