Failure to Assess and Obtain Consent Prior to Bed Rail Use
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy for the safe and effective use of bed rails for one resident. The facility’s policy, reviewed on 9/3/25, required that residents be assessed upon admission, readmission, or upon initiation of bed rail use using the Evaluation for Use of Bed Rails Assessment, that alternatives to bed rails be tried and evaluated, and that the risks and benefits of bed rail use be reviewed with the resident or representative and consent obtained prior to installation. Surveyors observed a resident with multiple diagnoses including hypothyroidism and dementia using bilateral upper side rails in the up position on three consecutive days. On review of the resident’s medical record, surveyors found no documentation of an evaluation of alternatives attempted, no documentation of the purpose or intended use of the side rails, and no documented discussion of risks and benefits with a signed consent for bed rail use. Additionally, there was no physician order for the bed rails. The DON confirmed that the resident had not been assessed for the use of bed rails and that the medical record lacked the required documentation of alternatives, intended purpose, physician order, and consent, despite the facility’s policy requirements. This failure created the potential for harm due to the risk for injury, entrapment, and/or death.
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