Failure to Assess, Document, and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to follow required procedures before installing and using bed rails (grab bars) for two residents. For both residents, staff did not attempt or document alternatives to bed rails prior to their use. Assessments completed by nursing staff indicated that bed rails or assist devices were not indicated for the residents at the time, yet bilateral grab bars were observed in use on both residents' beds. Staff interviews revealed a lack of awareness that grab bars are considered side rails and that alternatives should be tried and documented before use. Neither resident had a completed assessment for entrapment risk, nor was there evidence that the risks and benefits of bed rail use were reviewed with the residents or their representatives. Informed consent for the use of grab bars was not obtained or documented for either resident. The care plans and medical records did not reference the use of grab bars, and the required consent forms could not be located in the residents' charts. Staff, including the DON and Administrator, were unaware of the need for these steps and did not know that the residents were using bilateral grab bars. Both residents had significant medical conditions, including chronic kidney disease, diabetes, and generalized muscle weakness. One resident was cognitively intact and used the grab bars to assist with bed mobility, while the other was severely cognitively impaired and dependent on staff for mobility. Despite these conditions, the facility did not follow the necessary protocols for bed rail use, including assessment, documentation, and consent.