Failure to assess, document, and obtain informed consent for side rail use was identified for four residents. Residents had diagnoses including fracture, COPD, autism, seizures, dementia, falls, spinal stenosis, MS, HF, and acute respiratory failure with hypoxia, with cognition ranging from intact to severely impaired and two residents having legal guardians. Observations repeatedly showed both half side rails upright, while the DON and Administrator stated assessments should occur before side rails are placed and then quarterly.
Facility staff failed to obtain informed consent and complete bed rail assessments for six sampled residents with bed grab bars or assist bars in place. Records for these residents lacked signed consent, and some lacked current assessments after earlier documentation without consent. Observations repeatedly showed the bars upright on the beds, while staff interviews showed confusion about who was responsible for obtaining the consents and the DON and administrator stated the consent should be completed quarterly.
A facility failed to assess entrapment risk before installing bed rails and failed to verify that bed dimensions were appropriate for residents’ size and weight for three residents. One resident with MS and a history of falls had bilateral cane rails in use and had prior incidents in which an arm and shoulder were caught in the rail. Two other residents with severe cognitive impairment and fall histories also had bilateral cane rails, but their assessments lacked height, weight, and documentation that the rails fit their size and weight. Staff interviews showed the MDS Coordinator, DON, Maintenance Director, and Administrator were not aware of entrapment assessments, and the bed rail process did not include resident measurements or bed dimension checks.
Side rail use lacked required assessment, consent, care planning, and gap measurements for multiple residents. One resident with seizures had bilateral side rails and an informed consent form, but no documented safety gap measurements. Two other residents used grab bars for mobility, transfers, and repositioning, but their records lacked orders, risk-versus-benefit consent, and routine monitoring; one care plan did not address the grab bar use.
Missing Bed Rail Entrapment Assessments: Staff failed to document entrapment assessments for two residents with bed rails in place. One resident was cognitively intact with a seizure disorder and had bilateral U bars upright in bed; another was cognitively intact with MS and upper/lower extremity impairments and had a quarter-length bed rail upright. The Maintenance Director said the assessments were completed but not documented, and the Administrator said bed rail checks were expected.
The facility failed to document alternatives, risk-benefit review, informed consent, care planning, and ongoing assessments before and during side rail use for multiple residents. Several residents had side rails observed in the raised position, including one with a loose rail, while records lacked orders, safety assessments, measurements, and consent. Staff interviews showed inconsistent processes for evaluating and monitoring side rails, and the DON, ADON, MDS staff, and maintenance all described gaps in responsibility and documentation.
Quarterly bed rail assessments were missing for six residents whose records showed bed rails in use. Several residents had cognitive impairment or needed assistance with toileting, transfers, or rolling in bed, and staff observed bilateral or quarter-length side rails upright in multiple rooms. The MDS Coordinator said the assessments were his/her responsibility but some were not completed because he/she was busy, and the RN, DON, and Administrator stated quarterly assessments were expected.
Failure to assess bed rail entrapment risk and complete bed rail inspections: The facility did not document entrapment risk assessments or regular inspections of bed frames, mattresses, and bed rails for several residents using halo or quarter bed rails. Records showed residents with dementia, cognitive impairment, fractures, weakness, pain, and transfer/bed mobility needs had bed rail orders and consents, but the facility lacked documentation of proper risk assessment, and one safety check was completed for the wrong rail type. The DON and Maintenance Director stated the facility had no bed rail policy, no system to identify residents at risk for entrapment, and monthly checks were not consistently documented with actual measurements.
A resident with recent hospitalization and significant medical changes was not reassessed for bed rail use as required by facility policy. Staff failed to document an updated bed rail assessment after the resident's return, and the resident was later found entrapped between the bed rail and mattress, unresponsive and subsequently pronounced deceased. Interviews confirmed the lack of reassessment and documentation following the significant change in condition.
The facility failed to complete bed rail safety assessments, review risks and benefits, and obtain informed consent before bed rail use for multiple residents. Several residents had diagnoses such as muscle weakness, fractures, obesity, cognitive impairment, or debility, and observations showed half rails, quarter rails, or mobility bars in use while records lacked side rail assessments, entrapment risk assessments, consent, and in some cases physician orders or care plan documentation.
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