Failure to Assess, Document, and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to properly assess, document, and obtain informed consent for the use of bed rails for several severely cognitively impaired residents. In multiple cases, residents with significant physical and cognitive impairments, such as bilateral above-knee amputations, contractures, quadriplegia, and severe dementia, were found with bed rails in use without evidence of individualized assessment, documentation of risks and benefits, or informed consent from the resident or their representative. Staff interviews revealed that bed rails were routinely installed on all beds as a standard practice, regardless of individual resident need or ability to use the rails, and that assessments were often completed by copying information from previous assessments rather than through direct evaluation of the resident's current condition. Medical record reviews for the affected residents showed a lack of physician orders for bed rails, absence of care plans addressing bed rail use, and no documentation of discussions regarding the risks and benefits of bed rail use with residents or their representatives. In several instances, the Minimum Data Set (MDS) assessments did not indicate the use of bed rails, and care plans did not address their use, despite their presence on the residents' beds. Staff, including nurses and nurse aides, reported that residents were unable to use the bed rails due to their physical and cognitive limitations, and that the rails were primarily used to assist staff during care or to prevent residents from rolling out of bed, rather than for resident mobility or safety as intended. Interviews with facility leadership, including the DON, NP, and Administrator, confirmed that there was no process in place for obtaining informed consent or physician orders for bed rails, and that staff were not adequately trained on proper assessment procedures. The Administrator acknowledged that the issue was only recognized during the survey and that the facility's practices regarding bed rail assessments and use were not being executed correctly. Observations of the residents confirmed that bed rails were in use for residents who were nonverbal, unable to participate in their care, and physically incapable of using the rails for mobility or safety.