F0552

D

Failure to Inform Residents About Medications and Obtain Informed Consent for Bed Rails

Reseda, California Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The deficiency involves failure to uphold residents' rights to be informed of and participate in their treatment decisions, specifically regarding medication administration and use of bed side rails. For one resident with chronic respiratory failure and age-related osteoporosis, whose MDS documented intact cognitive skills and partial/moderate assistance needs for ADLs, a nurse administered multiple medications, including midodrine, Senokot-S, Trelegy Ellipta, Miralax, Tylenol, and Systane eye drops, without informing the resident of the name and indication of each medication at the time of administration. When questioned, the nurse stated she was not aware that providing this information was required by facility policy. The DON confirmed that residents have the right to be informed about their care, including medications, and that not providing this information restricted the resident from exercising this right. The facility’s administrative manual stated that residents have the right to make decisions about their medical condition and to accept or refuse proposed treatment.

The deficiency also includes failure to obtain informed consent for the use of bed side rails for another resident with hypertension and dysphagia, whose MDS also showed intact cognitive skills and partial/moderate assistance needs for ADLs. Review of the resident’s "Informed Consent for Bed Rail Use" form showed it was incomplete, lacking the resident’s or representative’s signature, the reason for side rail use, and the licensed nurse’s signature verifying that consent was obtained. The DON acknowledged that consent had not been obtained and no explanation was provided regarding the reason for side rail use. The facility’s bed rail policy required that, when the IDT determines bed rails are appropriate, the "Informed Consent for Bed Rail Use" form must be used prior to installation, with information presented in an understandable manner and consent given voluntarily and free from coercion.

Plan Of Correction

Joyce Eisenberg - Keefer Medical Center makes every effort to operate in substantial compliance with Federal and State laws and regulations. Nothing in this Plan of Correction is an admission otherwise. Joyce Eisenberg - Keefer Medical Center is submitting this Plan of Correction in compliance with its regulatory obligations and does not waive any objections it may have as to the merit or form of any allegations contained herein. Please note that the facility may contest the merits or form of any of the alleged deficient findings and may take reasonable steps to appeal them. This Plan of Correction constitutes Joyce Eisenberg - Keefer Medical Center's written credible allegation of compliance for the deficiencies noted.

F-552 Corrective Action for Affected Residents: The Director of Nursing (DON) met with LVN involved to provide 1:1 education regarding requirement. LVN reviewed Resident 59's current medication regimen and ensured that Resident 59 received information regarding the name of each medication, its indication, and the right to refuse medications and resident confirmed she is aware of medications as above. RN Unit Manager completed a comprehensive review of Resident 101's bed rail use and obtained informed consent from Resident 101, including explanation of the reason for bed rail use, risks, benefits, and alternatives. The DON or designee ensured that the Informed Consent for Bed Rail Use form was completed with appropriate signatures including Resident 101 and the licensed nurse verifying that consent was obtained. 3/17/26

Identifying other Residents having the Potential to be Affected: As most residents have medications, DON or designee provided education to licensed nurses on the requirement to provide information regarding the name of each medication, its indication, and the right to refuse medications as applicable. DON educated residents during the 3/19/26 Resident Council meeting regarding their right to be informed on their medications.The Medical Records Manager conducted an audit of other residents currently utilizing bed rails. The RN Unit Managers reviewed the Informed Consent for Bed Rail Use forms to ensure that informed consent was obtained, forms are completed in their entirety including resident or resident representative signature, reason for use, and licensed nurse signature. For residents with incomplete consent forms, the RN Unit Managers or designee obtained proper informed consent including explanation of risks, benefits, and alternatives.

Measures put into place or Systemic Changes: The DON or designee in-serviced LVNs and RNs on the requirement to inform residents of medication names and indications prior to administration, the resident's right to be informed of and participate in treatment decisions, and the resident's right to refuse medications. The in-service included review of the facility's Administrative Manual regarding resident rights to make decisions about medical treatment and to accept or refuse proposed treatment.The DON or designee in-serviced LVNs and RNs on the facility's Bed Rails policy and procedure, including the requirement to obtain informed consent prior to bed rail installation, proper completion of the Informed Consent for Bed Rail Use form including resident or resident representative signature, documentation of the reason for bed rail use, explanation of risks, benefits, and alternatives, and licensed nurse signature verifying consent was obtained.

Plan to Monitor Performance: RN Unit Manager or designee will begin conducting medication administration observations for a sample of residents with intact cognitive skills for daily decision making. The observations will verify that nursing staff inform residents of medication names and indications prior to administration. These observations will be conducted weekly for four weeks, then monthly for three months.

Medical Records department will begin auditing Informed Consent for Bed Rail Use forms for residents utilizing bed rails to ensure forms are completed in their entirety including resident or resident representative signature, reason for bed rail use, and licensed nurse signature. The audits will be conducted weekly. The "Stand Up Meeting Routine Questionnaire" form was updated to include verification of consent for bed rails. Medical Records Manager or designee will report monitoring plan results to the Quality Assurance and Performance Improvement (QAPI) committee. The Quality Assurance and Performance Improvement (QAPI) committee will monitor on an ongoing basis until substantial compliance of the set-forth protocol is achieved.