F0700

D

Unnecessary Bed Rail Use Without Assessment, Orders, or Consent

New Castle, Delaware Survey Completed on 12-13-2025

Penalty

No penalty information released

Summary

The facility failed to ensure that bed rails in use were necessary for one resident reviewed for accidents. The resident was admitted with diagnoses including anoxic brain damage and persistent vegetative state and was documented on the admission MDS as totally dependent on staff for all ADLs, including bed mobility and transfers, with no bed rails indicated. Review of the physician’s orders and the comprehensive care plan showed no orders or care plan addressing the use of bed rails, and the record contained no documentation of informed consent for bed rail use. The facility’s bed rail policy required that bed rails be used only to treat a medical condition and enhance functional abilities, and that risks and benefits be evaluated and reviewed with the resident or representative, with informed consent obtained prior to installation.

Despite the absence of orders, care plan, or consent, multiple observations over several days showed the resident lying in bed in a vegetative state, unable to move, with grab bars (short bed rails) raised on both sides of the bed during each observation. During an observation with an LPN, the LPN confirmed that the grab bars were raised on both sides, that the resident was unresponsive and unable to move at all, and that the resident was completely dependent on staff for all ADLs, noting the grab bars were usually in the raised position. In an interview, the DON confirmed the resident was unresponsive, unable to use the grab bars in any way, and stated the grab bars should not have been installed on the resident’s bed. These findings demonstrated that the facility did not follow its own policy requirements to assess necessity, evaluate risks and benefits, review them with the resident/representative, and obtain informed consent before installing and using bed rails for this resident.