Bed Rail Installed Without Required Physician Order
Penalty
Summary
The facility failed to obtain appropriate physician orders prior to installing a bed rail for one resident reviewed for bedrails. The resident was admitted on an unspecified date, and record review of the physician orders showed no order for the use of bedrails. During an observation and interview in the resident’s room, surveyors noted a quarter-size bedrail on the upper left side of the bed, and the resident confirmed he uses the side rail for mobility and to reposition himself. In a subsequent interview, the DON confirmed that the resident did not have physician orders for the use of bedrails and acknowledged that such orders should be in place prior to installation. This deficiency occurred despite regulatory expectations that, before using a bed rail, the facility should assess the resident for safety risk, review risks and benefits with the resident or representative, obtain informed consent, and correctly install and maintain the bed rail.
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