Unauthorized Use of Bed Rails as Physical Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints imposed for staff convenience and not required to treat a medical symptom. Specifically, half bed rails were used on both sides of the resident's bed without a physician's order or proper assessment. The resident, a female with multiple diagnoses including type 2 diabetes, hypertension, gastrointestinal disease, pain, constipation, hyperlipidemia, and atrial fibrillation, was moderately cognitively impaired and dependent on staff for bed mobility, repositioning, and transfers. Her care plan did not address the use of bed rails or identify her as a fall risk, and there was no documentation of a medical need for the bed rails. Observations on two occasions confirmed that the half bed rails were up on both sides of the resident's bed. The resident reported that she had not requested the bed rails and was told by staff that they were used to keep her in bed and prevent her from getting up. She stated that the bed rails did prevent her from getting up, but she had not been injured or attempted to get out of bed herself. She also indicated that she did not use the bed rails to reposition herself and did not have a preference regarding their use. Interviews with staff revealed inconsistent understanding and application of the facility's restraint and bed rail policies. A CNA stated that bed rails were used to keep residents in bed, especially if they were a fall risk, and that a physician's order was required, which was not present for this resident. The RN and DON both confirmed that an assessment and physician's order were required for bed rail use, but neither knew when or why the bed rails were initiated for this resident. The facility's policy prohibits the use of physical restraints for convenience and requires medical justification and proper authorization for their use.