F0700

E

Failure to Assess, Order, and Obtain Consent for Bed Rail Use

Roswell, New Mexico Survey Completed on 12-18-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow required processes before and during the use of bed rails for multiple residents. The facility did not consistently obtain physician orders, complete entrapment risk assessments, review risks and benefits with residents or their representatives, obtain informed consent, or ensure that bed rail use was reflected in care plans and Minimum Data Set (MDS) assessments. Surveyors observed quarter-size bed rails in use for 13 residents, while corresponding medical records frequently lacked documentation of orders, assessments, consents, and in some cases care plan interventions for bed rail use. The report states that this deficient practice has the potential to cause serious injury by residents becoming trapped between the mattress and bed rail.

For one resident with morbid obesity, muscle weakness, lack of coordination, and need for assistance with personal care, surveyors observed quarter-size bed rails on both upper sides of the bed. The care plan contained no interventions for bed rail use, and the electronic health record lacked a physician order, entrapment risk assessment, and consent, although bed dimensions were documented as appropriate. Another resident with schizophrenia, dementia, parkinsonism, major depressive disorder, and anxiety had quarter-size bed rails in place and used them for positioning and mobility; the care plan documented bed rail use, but there were no physician orders, entrapment assessments, or consents. A resident with multiple medical conditions including ESRD, muscle weakness, and heart failure had 1/4 side rails in use and care plan documentation for assist bars, but the record lacked an entrapment risk assessment, risk/benefit review, consent, and documentation of appropriate bed dimensions.

Additional residents with diagnoses such as muscle wasting/atrophy, COPD, asthma, epilepsy, generalized muscle weakness, spinal stenosis, depression, insomnia, anxiety, and history of falls were also observed with quarter-size bed rails in use. For several of these residents, care plans either did not include bed rail interventions or were updated only after surveyor observations, and physician orders for bed rails were often missing. In multiple cases, MDS assessments and care plans did not reflect actual bed rail use, and medical records lacked documentation of entrapment risk assessments, risk/benefit discussions, and informed consent. Some residents and a representative confirmed that bed rails were used for positioning, mobility, and transfers. The Administrator and DON acknowledged during interviews that residents did not have the appropriate requirements in place for bed rails, including therapy assessments/referrals, physician orders with indication of use, education with consent, and updated care plans.

The pattern across all 13 residents reviewed for accidents shows that bed rails were installed and in use without the facility completing the required safety and consent processes. Several residents had quarter-size bed rails on both sides of the bed despite the absence of corresponding physician orders and documentation in the care plan or MDS. The report notes that for each of these residents, there was no documented assessment for risk of entrapment and no documented review of risks and benefits or consent for bed rail use, even though bed dimensions were often documented as appropriate for the resident’s size and weight. This systemic failure to assess, document, and obtain consent for bed rail use constitutes the cited deficiency.