Failure to Assess, Document Alternatives, and Obtain Consent Before Bed Rail Use
Penalty
Summary
The deficiency involves the facility’s failure to complete and document required assessments and consents before installing and using bilateral quarter bed rails for one resident reviewed for accidents. The resident had an annual MDS showing a BIMS score of 11, indicating moderate cognitive impairment, and active diagnoses of Parkinson’s disease and dementia. The MDS also documented that the resident required substantial to maximum staff assistance for rolling in bed and moving from lying to sitting at the side of the bed. On two separate observations, the resident was seen in bed with bilateral quarter side rails in the up position during a nap and later the same day. Record review showed no evidence that alternatives to bed rails were attempted, no bed rail safety assessment, no documentation that risks and benefits were reviewed with the resident or representative, no informed consent, and no bed rail care plan for the use of bilateral bed rails. During interviews, a CNA stated the resident required assistance to turn in bed and used a hoyer lift for transfers, and that the resident did not use the bed rails. An LPN stated the resident had Parkinson’s disease with hand tremors and needed staff to guide her hands to the bed rails and direct her to hold on, after which the resident would hold on. In a combined interview with the NHA and DON, no bed rail information dated prior to the surveyor’s inquiry was provided, confirming the lack of required documentation prior to installation and use of the bilateral bed rails.
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