Failure to Assess, Document, and Safely Install Bed Rails
Penalty
Summary
The facility failed to ensure that appropriate alternatives to bed rails were identified and attempted before installing bed rails for a resident with significant neurological and physical impairments. Documentation showed that no less restrictive measures or alternatives were tried, despite facility policy requiring such steps. The decision to use bed rails was based on a family request, and staff complied without conducting a thorough evaluation or identifying a medical symptom that necessitated the use of bed rails. The resident was dependent on staff for all bed mobility and transfers, was non-verbal, unable to follow commands, and not oriented, which placed them at higher risk for entrapment and injury according to FDA guidance. The assessment process for bed rail use was incomplete and lacked critical information. Key assessment forms had unanswered questions regarding the resident's bed mobility, balance, trunk control, and the specific reason for device use. The interdisciplinary team documentation indicated that the bed rail was considered solely due to a patient or family request, without evidence of a comprehensive risk-benefit analysis or informed consent process as required by facility policy. Additionally, there was no documented assessment of the compatibility between the bed, mattress, and bed rail prior to installation. Installation of the bed rails was performed by a licensed nurse who was not trained for this task, rather than by the maintenance department as per facility protocol. The maintenance director confirmed that no request for bed rail installation was made, and the nurse admitted to installing the rails after hours to accommodate the family's wishes. The bed was not measured or assessed for safety prior to installation, further deviating from established procedures and increasing the risk of resident harm.