Failure to Assess and Document Medical Need for Bed Rail Use
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints, specifically bed rails, without proper evaluation for medical necessity. Three residents were observed with both side bed rails raised on their beds, yet none had physician orders or documented assessments justifying the use of bed rails. Interviews with residents and their representatives revealed that the bed rails were not requested by the residents and were instead implemented by staff, often as a measure to prevent falls. One resident was observed attempting to get out of bed while the bed rails were up, indicating a lack of individualized assessment for their use. Staff interviews demonstrated inconsistent understanding and application of restraint policies. Some staff members believed that bed rails did not require a physician's order and did not consider them restraints, while others stated that an order and assessment were necessary. The Director of Nursing acknowledged that the facility aimed to be restraint-free but admitted that bed rails were used for mobility assistance and to prevent falls, despite some incidents of bruises and skin tears associated with their use. There was no evidence that residents had been properly assessed for the risks and benefits of bed rail use, nor that informed consent had been obtained prior to installation. Facility policy required assessment for risk of entrapment, review of risks and benefits, and informed consent before bed rails were used, but these steps were not documented or followed for the residents in question. Observations confirmed that bed rails were in use for multiple residents during the survey, and staff interviews further highlighted a lack of training and awareness regarding restraint policies and the potential for bed rails to be considered restraints.