Failure to Assess, Document, and Obtain Consent for Bed Grab Bar Use
Penalty
Summary
The facility failed to identify and attempt alternatives prior to installing or using grab bars on beds for two residents. For one resident with intact cognition and diagnoses including Type 2 diabetes and chronic heart failure, the care plan indicated independent bed mobility and use of bilateral grab bars. Although an informed consent form was signed, there was no evidence in the electronic health record (EHR) that a grab bar assessment had been completed to determine necessity or safety. The resident confirmed using the grab bars and recalled signing paperwork but could not remember the details. For another resident with severely impaired cognition, dementia, and a history of stroke, the care plan required assistance of two staff for bed mobility and transfers but lacked information about grab bars. The EHR for this resident also lacked evidence of a grab bar assessment, education on risks, or a signed consent form. The resident's wife was unaware of any discussion about risks or paperwork regarding the grab bars. Staff interviews revealed inconsistent documentation practices. Registered nurses and LPNs stated that a nurse manager was responsible for completing grab bar assessments, which were reportedly done on paper and placed in the resident's paper chart. However, neither the assessments nor the consents could be located in the EHR or paper records for the two residents. The facility's policy required assessment of alternatives, risk of entrapment, discussion of risks and benefits, and informed consent prior to grab bar installation, but these steps were not documented or verifiable for the affected residents.