Failure to Implement Ordered Bed Rails and Complete Bed Rail Assessment
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to conduct accurate assessments and ensure appropriate use of bed rails for one resident. Facility policy dated 8/27/25 stated that bed rail use is prohibited unless specific criteria are met, including attempts to use alternatives, an interdisciplinary evaluation, resident assessment, and informed consent. The resident involved was admitted with diagnoses including schizophrenia, bipolar disorder, and paralytic syndrome. A physician order dated 1/19/26 directed the use of bilateral grab bars on the bed to assist the resident with self-positioning, and the resident’s care plan dated the same day also specified bilateral grab bars. Despite these orders and care plan directives, an observation on 1/20/26 showed that the resident’s bed did not have the ordered bilateral grab bars. Review of the resident’s Enabler Bar assessment indicated that therapy had recommended bilateral grab bars, but the nursing portion of the assessment was left blank. During an interview, the resident reported that the facility had promised to provide side rails to assist with self-positioning in bed and that they still had not been provided. A registered nurse confirmed that the bed lacked the ordered bilateral grab bars and acknowledged that the facility failed to conduct accurate assessments to ensure bedrails were used to meet the resident’s needs and to address the risks associated with bedrail usage.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.