Failure to Assess, Educate, and Obtain Consent for Bed Rail Use; Improper Padding Practices
Penalty
Summary
The facility failed to assess residents for the risk of entrapment prior to the installation of bed rails and did not review the risks and benefits of bed rail use with the residents or their representatives, nor did it obtain informed consent. This deficiency was identified for four residents with seizure disorders and varying degrees of cognitive impairment. Documentation in the medical records did not show evidence of risk assessments, education, or consent related to the use of bilateral quarter side rails, despite physician orders and care plans indicating seizure precautions and the use of side rails with padding. Observations revealed that instead of using proper side rail pads, staff frequently substituted blankets and pillows, which were taped or placed over the side rails. Staff interviews confirmed that this practice was common, especially when pads were unavailable, and that locating proper pads was often difficult. The DON, Administrator, and other nursing staff expressed the belief that blankets and pillows provided adequate padding and did not recognize the potential risks of suffocation or entrapment associated with these substitutes. However, a nurse practitioner and the bed manufacturer both indicated that using blankets or pillows could create gaps and increase the risk of entrapment, especially for residents with impaired cognition. The facility's policy required bilateral side rails with padding for residents with seizure diagnoses, but there was no evidence that the facility ensured the side rails and padding were correctly installed or maintained. Observations showed inconsistent and improper padding, and staff interviews revealed a lack of awareness regarding the need for proper assessment, documentation, and the risks associated with makeshift padding. The failure to assess, educate, obtain consent, and use appropriate equipment resulted in a situation of Immediate Jeopardy and Substandard Quality of Care, with a likelihood of serious harm to residents using bed rails.