F0700

D

Failure to Assess Bed Rail Safety and Obtain Informed Consent

Dodge City, Kansas Survey Completed on 03-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to assess a resident for safety related to bed rail use and to obtain informed consent prior to using bed rails. The resident had diagnoses including vascular dementia, anxiety, delirium, and major depressive disorder, with documentation of severe cognitive impairment, memory problems, and being never or rarely understood per the MDS and CAA. The resident’s care plan noted an alteration in musculoskeletal status related to broken bones in the left wrist/forearm, and the facility documented that his bed was replaced with one without bed rails following an incident. However, the resident’s EHR contained no bed rail risk assessment from admission onward, and there was no evidence that the resident or his representative had been provided information about risks and benefits or had given informed consent for bed rail use.

Surveyor interviews and record reviews showed that, prior to the incident involving this resident, the facility had no nursing bed rail safety assessment process in place, despite having 25 residents with at least one bed rail attached to their beds. The Administrative Nurse acknowledged that no nursing bed rail safety assessments had been conducted since her hire and confirmed that no informed consent had been obtained for this resident’s bed rail use. Maintenance staff reported performing general safety checks and provided inspection logs that referenced checking for safety and fall risks but did not specifically address bed rails, and there were no inspection logs specific to bed rails. The facility’s own Bed Safety and Bed Rails policy required attempts to use alternatives, IDT evaluation, resident assessment, and informed consent before bed rail use, but these steps were not carried out or documented for this resident.