F0700

E

Failure to Obtain Orders and Informed Consent for Bed Rail Use

Clovis, New Mexico Survey Completed on 12-05-2025

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s process for assessing, ordering, and obtaining informed consent for bed rail use. Facility policy requires that before using bed rails, staff try alternative approaches, assess the resident for safety risk, review risks and benefits with the resident or representative, obtain informed consent, and correctly install and maintain the bed rail. For one resident with spondylolysis of the cervical spine, osteoarthritis, reduced mobility, muscle weakness, and paraplegia, the record showed a completed bed rail assessment recommending quarter-size bed rails on both upper sides of the bed. However, review of the electronic health record revealed there was no physician order for bed rails and no informed consent on file. During observation, quarter-size bed rails were present on both upper sides of this resident’s bed, and in interview the resident confirmed using the bed rails for repositioning.

For another resident with sciatica on the left side, muscle weakness, abnormalities of gait and mobility, and lack of coordination, the record showed a bed rail assessment recommending quarter-size bed rails on both upper sides of the bed. The electronic health record contained a physician order for quarter-size bed rails as an enabler for turning and repositioning, but there was no informed consent documented. Observation confirmed quarter-size bed rails on both upper sides of this resident’s bed, and the resident reported using the rails for repositioning. In an interview, the DON confirmed that both residents were using quarter-size bed rails on both upper sides of their beds, that one resident did not have a physician order or informed consent, and that the other resident did not have informed consent, despite facility requirements.