Failure to Obtain Orders and Complete Assessments Prior to Bed Rail Installation
Penalty
Summary
The deficiency involves the facility’s failure to obtain appropriate physician orders and complete required assessments before installing bed rails for a resident. The resident was admitted on a specified date, and record review showed no physician order for bed rail use, a bed rail assessment indicating the resident did not need bed rails, and a baseline care plan without any interventions for bed rails or mobility enablers. Despite this documentation, surveyors observed quarter-length bed rails installed on both upper sides of the resident’s bed, and the resident reported using the side rails for mobility and repositioning. In an interview, the Interim DON confirmed that one resident’s physician orders lacked the size and indication for bed rail use and that this resident had no physician orders or assessment documenting the need for bed rails prior to their installation. These findings show that the facility did not follow its own process of assessing safety risk, reviewing risks and benefits with the resident/representative, obtaining informed consent, and correctly ordering and documenting bed rail use before installation.
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