Failure to Assess and Document Alternatives Prior to Bed Rail Use
Penalty
Summary
The deficiency involves the facility’s failure to follow its own bed rail policy requiring that appropriate alternatives be attempted and evaluated before installing bed rails, and that residents or their representatives be provided sufficient information to make an informed decision. The policy, revised in August 2017, states that alternatives must be tried prior to installing side or bed rails and that, if rails are used, the facility must ensure correct installation, use, and maintenance. The policy also requires documentation of the assessed medical needs addressed by bed rails, the expected benefits and likelihood of those benefits, the risks and how they will be mitigated, and the alternatives attempted that failed or were considered inappropriate. For one resident reviewed for bed rails, the facility did not document that these requirements were met. The resident was admitted with multiple diagnoses, including acute respiratory failure with hypercapnia, schizoaffective disorder, and AFib. During observation, the resident was noted to have bilateral upper side rails in use. However, the medical record lacked documentation of any evaluation of alternatives attempted, any explanation of how those alternatives failed to meet the resident’s needs, and any documentation of the purpose or intended use of the side rails. In an interview, the DON confirmed that the resident did not have a side rail assessment completed and acknowledged that such an assessment should have been done.
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