Failure to Obtain Consent and Safely Install Bed Rails
Penalty
Summary
The deficiency involves the facility’s failure to obtain informed consent for bilateral bed rails, and to ensure bed rails were safely and securely installed and maintained. Facility policy dated August 2022 required that bed rails be properly installed and that informed consent be obtained prior to use. The resident involved had multiple medical diagnoses, including COPD, a fractured left tibia, muscle disorders, lack of coordination, gait abnormalities, muscle wasting, phantom limb syndrome, and a right above-the-knee amputation. The physician order sheet documented an order only for a left half side rail in the up position while in bed to enhance bed mobility, with staff directed to check the positioning and functioning of the device. A consent form dated 2/7/25 documented the resident’s consent for use of a left half side rail only. A health status note documented that staff heard the resident yelling and found her on the floor next to her bed, with the left side rail on the floor beside her. The resident reported she had attempted to sit up on the side of the bed using the side rail when it fell off the bed frame, causing her to fall with it. During observation, the resident’s bed was found to have both right and left half side rails, and the right rail was loose and moved significantly from side to side. The Maintenance Director stated that nursing staff often remove or replace side rails and do not secure them properly, and he believed this occurred when the resident’s bed rail came off and caused her fall. He confirmed the bed rail had not been properly secured and that the bed currently had two rails, with the right rail not properly secured and posing a hazard, and that there was no physician order or consent for a right-side rail. The DON confirmed that only maintenance staff were permitted to remove and install bed rails, that bed rails must be installed correctly to ensure safety, and that the rail came off the frame when the resident attempted to use it.
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