Failure to Assess Bed Rail Need and Obtain Informed Consent
Penalty
Summary
The deficiency involves the facility’s failure to properly assess the need for bed/side rails and obtain informed consent, including discussion of risks and benefits and assessment of entrapment risk, for two residents who were using side rails. For one resident with severe cognitive impairment, epilepsy, traumatic brain injury, tracheostomy status, and total dependence for all ADLs, the care plan documented use of a wide low air loss mattress and bilateral side rails, but there was no physician order for side rails in the EMR. A bed rail assessment indicated side rails/assist bar were used as an enabler to promote independence and included the resident representative’s signature, but there was no documentation that risks versus benefits were explained, no assessment of entrapment risk, and no indication that alternatives were tried before using bed rails. Observations showed this resident in a low bed with side rails in use and fall mats in place, and a CNA stated the side rails were used to keep the resident in bed so she did not fall, while also stating the resident had not fallen from bed and could not grab or use the side rails. For a second resident with severe cognitive impairment, functional limitations in upper and lower extremities, a feeding tube, and diagnoses including Alzheimer’s disease, epilepsy, and cerebrovascular accident, there was a physician order for bilateral upper side rails for safety without specified directions. The care plan for falls and safety included bilateral side rails to ensure safety, and the bed rail assessment documented the reason for side rail use as keeping the resident in bed. The assessment included the resident representative’s signature but lacked documentation that risks versus benefits were explained, did not assess entrapment risk, and did not show that alternatives were attempted before side rail use. Observations showed this resident in a low bed with fall mats and contracted hands with cloth rolls, and a CNA reported the side rails were for falling and that the resident could not grab or use them. An RN stated that side rail assessments did not include risks versus benefits or entrapment risk and that she was unsure what alternatives had been tried, and also reported that there was no facility policy for side rails. The surveyors noted that this failure had the potential to place residents at risk of injury or death.
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