Failure to Assess Bed Rail Entrapment Risk and Obtain Informed Consent
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective system to assess residents for the risk of entrapment from bed rails, to monitor and document the ongoing need for bed rails, and to obtain and document informed consent after discussing risks and benefits with residents or their representatives. For four sampled residents, the facility used various bed rails or grab bars without documented evidence of entrapment risk assessment or informed consent. The facility’s own Siderail Data Collection assessments were incomplete, with key sections such as comments and summaries left blank, and no documentation that entrapment risk was evaluated. Additionally, subsequent required reassessments were not completed after the initial dates noted in the records. For one resident with diagnoses including heart failure, acute kidney failure, chronic atrial fibrillation, and diabetes, a Siderail Data Collection assessment documented poor bed mobility, use of side rails for positioning, and a desire to have side rails raised, but contained no comments or summary and no evidence of entrapment risk assessment. A later Nursing Quarterly/Annual/Significant Evaluation assessment indicated the resident did not have any potential restraints, which automatically disabled the side rail review questions, leaving them unanswered. There was no documentation that risks and benefits of side rail use were discussed or that informed consent was obtained, even though observations showed half-length bed rails in the upright position on both sides of the bed, which the resident reported using for bed mobility. Another resident with fibromyalgia, rheumatoid arthritis, low back pain, Alzheimer’s disease with late onset, and dementia had a Siderail Data Collection assessment indicating poor bed mobility, use of side rails for support, and balance difficulties, but again with no comments, no summary, and no documented entrapment risk assessment. The Nursing Quarterly/Annual/Significant Evaluation similarly recorded that the resident had no potential restraints, disabling the side rail review section and leaving all related questions unanswered. No evidence was found that risks and benefits of bed rail use were discussed with the resident or representative or that informed consent was obtained, despite observations of a bed grab bar secured to the bedframe and in the upright position. A third resident with heart failure, COPD, and hypertension had a Siderail Data Collection assessment showing poor bed mobility, use of side rails for support, balance difficulties, and a history of falls, with assist rails/quarter rails selected as the device type. However, there were no comments, no summary, and no documentation of entrapment risk assessment, and no further Siderail Data Collection assessments after the initial date. The Nursing Quarterly/Annual/Significant Evaluation again marked that the resident had no potential restraints, disabling the side rail review questions, and there was no evidence of any discussion of risks and benefits or informed consent for bed rail use. Observations showed quarter-length bed rails in the upright position on each side of the bed, which the resident stated were used for repositioning. A fourth resident with Parkinson’s disease, cerebral infarction, and dementia had a Siderail Data Collection assessment documenting poor bed mobility, use of side rails for support, balance difficulties, and a history of falls, with assist rails/quarter rails selected. As with the other residents, the assessment lacked comments and a summary, and there was no evidence of an entrapment risk assessment or any subsequent Siderail Data Collection assessments. The Nursing Quarterly/Annual/Significant Evaluation recorded no potential restraints, disabling the side rail review questions and leaving them unanswered. The record contained no documentation that risks and benefits of bed rail use were discussed with the resident or representative or that informed consent was obtained, even though repeated observations showed quarter-length bed rails in the upright position on both sides of the bed. Interviews with the DON and Administrator confirmed that the consolidated nursing assessment format caused the bed/side rail review questions to be skipped when staff selected that a device was not a restraint, and that informed consent had not been obtained for residents using grab bars, quarter-length, or half-length bed rails.
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