Failure to Obtain Consent and Document Bed Rail Use
Penalty
Summary
The facility failed to review the risks and benefits of bed rail use with a resident or their representative and did not obtain informed consent prior to installing a bed rail. Specifically, a one-half length bed rail was installed on the right side of a resident's bed without a physician order, without documented informed consent, and without inclusion of bed rail use in the resident's comprehensive care plan. The resident's care plan did not address bed rail use, despite the resident being identified as high risk for falls with a history of falls prior to admission. The electronic medical record and active physician orders did not contain any documentation authorizing bed rail use or consent for its installation. Staff interviews confirmed the absence of a physician order and informed consent for the bed rail, and the DON acknowledged that the lack of an order prevented the addition of bed rail use to the care plan. The facility's policy required consent and care plan documentation for side rail use, but these steps were not followed. The resident was observed using the bed rail and expressed that it made her feel safe and aided her mobility, but the required assessments, documentation, and consents were not completed as per facility policy.