Failure to Obtain Physician Order Prior to Bed Rail Installation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to obtain appropriate physician orders prior to installing and using bed rails for one resident. The resident was admitted on a documented admission date, and record review showed that the resident’s bedrail assessment, completed on a specified date, indicated the resident uses bedrails to enhance mobility. However, review of the resident’s physician orders revealed no order for the use of bedrails. During observation of the resident’s room, quarter-size bedrails were seen on the upper right and left sides of the bed, and in an interview the resident confirmed using the bedrails for mobility and repositioning. 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 sequence of events—installation and use of bedrails documented in the assessment and observed in the room, resident-reported use of the rails, and the absence of corresponding physician orders—constituted the cited deficiency for one of two residents reviewed for bedrails.
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