Failure to Attempt Alternatives and Assess Entrapment Risk Before Bed Rail Use
Penalty
Summary
The facility failed to attempt alternatives prior to the installation and use of bed rails and did not assess for risk of entrapment when completing assessments for one resident. The resident was admitted with a diagnosis of hypertension and was cognitively intact, independent with bed mobility and transfers, and had no recent falls or behavioral issues. Despite these factors, bilateral quarter bed rails were ordered and installed to promote bed mobility, with the stated goal of preventing decline in bed mobility. Documentation revealed that the resident had a physician's order for the bed rails and had given verbal consent after being informed of potential risks and benefits. However, there was no evidence in the assessment or care plan that any alternatives to bed rail use had been attempted or considered prior to installation. Additionally, the assessment did not include an evaluation for risk of entrapment associated with the use of bed rails. Interviews with facility staff, including the DON, Maintenance Director, Therapy Director, and Administrator, confirmed that no alternatives had been tried and that there was no documentation of such attempts. Staff also could not provide records of a therapy or nursing assessment supporting the need for bed rails or documenting failed alternatives. The Maintenance Director reported conducting safety inspections and checking for entrapment risk during installation, but this was not documented in the resident's assessment.