Failure to Assess, Document, and Monitor Bed Rail Use for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to have a bed rail/side rail policy and to comprehensively assess, document, and monitor the use of bed rails for three residents. The facility did not develop a side rail/bed rail policy, and the DON was unable to state where risks and benefits were documented or how often side rails were reassessed. Enabler Device Assessments for the residents noted that risks and benefits of side rail use were explained, but the medical records lacked documentation of what specific risks and benefits were discussed, and there was no evidence of ongoing monitoring or maintenance of the bed rails. For one resident with heart failure, a fall with weakness, and moderate cognitive impairment, the Enabler Device Assessment indicated use of a half side rail to maximize independence and stated that risks and benefits were explained, but did not specify the number or location of rails or detail the risks and benefits. The ADL care plan documented use of a quarter side rail to assist with bed mobility. Multiple observations showed this resident in bed with both upper side rails raised while eating meals and resting. During interviews, the resident was unable to state whether they could use the side rails for turning or even place their hand on the rail, while an agency NAC reported that the resident required two-person assistance for bed mobility and stated the resident was able to use the side rails. Another resident with muscle weakness and a stroke with left-sided weakness, and no cognitive impairment, had a physician order and care plan indicating use of bilateral bedrails to maximize independence with turning and repositioning, but the order did not specify whether upper or lower rails were used. The Enabler Device Assessment again stated that risks and benefits were explained without documenting what they were or specifying the rail configuration. Observations repeatedly showed this resident in bed with both upper side rails raised while eating meals. A third resident with high blood pressure and dementia, dependent on staff for bed mobility and transfers, had a care plan allowing bilateral quarter side rails to assist with bed mobility, and an Enabler Assessment documenting use of a half rail, ability to remove it independently, and that risks and benefits were discussed with a family member who gave verbal consent. However, the record did not specify the number or location of rails or the content of the risk/benefit discussion, and observations showed both upper side rails raised when the resident was in bed or when the bed was unoccupied.
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.