F0700

E

Failure to Assess, Document Consent, and Evaluate Entrapment Risk for Bed Rail Use

Cary, North Carolina Survey Completed on 12-31-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow required processes before implementing and using bed rails for four residents. The facility did not complete bed rail assessments that documented alternatives tried prior to bed rail use, did not assess for entrapment risk, and did not consistently obtain and document informed consent. Surveyors found that for all four residents reviewed for side rails, there were missing or incomplete assessments, absent documentation of alternatives, and no recorded entrapment risk evaluations, despite bed rails being in use.

For one resident with congestive heart failure and a below-the-knee amputation, the MDS showed the resident was cognitively intact, independent with rolling in bed, and required supervision to move from lying to sitting. The care plan did not address bed rail use. A bed rail assessment signed by a nurse lacked documentation of alternatives considered and did not include an entrapment risk assessment. During observation, a half-circle bed rail was raised on the bed, and the resident reported using it to roll and sit up, was unsure if it could be lowered, and stated it had always been present. Interviews with nursing, therapy, the DON, and the Administrator revealed that therapy was believed to be responsible for assessments and entrapment evaluations, but the Therapy Manager stated she had never heard of a bed rail risk assessment and that any attempts at alternatives were only scattered in therapy notes.

For a second resident with heart failure and severe cognitive impairment, the MDS indicated no upper extremity impairment, lower extremity impairment, and a need for supervision or partial/moderate assistance for bed mobility. The bed rail assessment did not document alternatives, lacked an RN signature to indicate risk/benefit education and consent, and did not include an entrapment risk assessment. The care plan did not address bed rails, yet a rectangular bed rail was observed in the raised position, and the resident reported using it to roll and sit up, also unsure if it could be lowered. Similar interview findings showed that nursing believed therapy completed assessments and entrapment evaluations, while therapy reported no formal bed rail risk assessment process and inconsistent handling of education and consent.

For a third resident with chronic respiratory failure who was cognitively intact and independent with bed mobility, the care plan did not address bed rail use. A bed rail assessment signed by a nurse did not document alternatives to bed rails and did not include an entrapment risk assessment. Observations showed bilateral rectangular bed rails in the raised position while the resident was in bed and later sitting in a chair next to the bed. Staff interviews again reflected that therapy was thought to be responsible for assessments and entrapment evaluations, but the Therapy Manager denied knowledge of a formal bed rail risk assessment and stated that any alternatives tried were only reflected in scattered therapy notes.

For a fourth resident with an anxiety disorder who was cognitively intact and required supervision or partial/moderate assistance for bed mobility, the care plan did not address bed rail use. The medical record contained no bed rail assessment, no consent for bed rail use, and no entrapment risk evaluation, despite bilateral half-circle bed rails being observed in the raised position. The resident reported using the bed rails to roll and sit up and stated they had been present since admission. Interviews revealed that nursing believed therapy completed assessments and that an RN would sign after consent, while the Therapy Manager believed this resident had not been assessed because the bed rails may have been present when the resident transferred from assisted living. The DON and Administrator both indicated they believed therapy completed entrapment risk evaluations and attempted alternatives, but they did not know where such documentation could be found, and the Administrator was unaware that the grab bars in use were considered bed rails.