Failure to Assess Bed Rail Safety and Need Before Use
Summary
The facility failed to ensure that five of six residents reviewed for bed rails were assessed for safety and need before bed rails were used. The report states that the facility’s Bed Rail Safety policy required assessment of the resident’s needs and risks, including risk of entrapment between the mattress and bed rail or in the bed rail itself, before determining whether bed rails met the resident’s needs. For R11, the admission record showed diagnoses including COPD, SOB, and pneumonia, and the MDS showed severely impaired cognition with substantial/maximal assistance needed for bed mobility and sitting up and dependence for transfers. Admission assessments documented that R11 did not desire bed rails, was not using them, and that bed rails would not assist with turning or transfers; the entrapment review was not completed and bed rails were documented as not indicated. Despite this, R11 was observed in bed with bilateral bed rails up, and the UM confirmed the rails were present on the hospice bed but was unsure whether an assessment was needed when the hospice bed with rails was implemented. For R13, the admission record showed diagnoses including encephalopathy, respiratory failure, dementia, malnutrition, and dysphagia, and the MDS showed moderately impaired cognition with substantial/maximal assistance needed for bed mobility and dependence for transfers. Admission assessments documented that R13 did not desire bed rails, was not using them, and that bed rails would not assist with turning or transfers; the entrapment review was not completed and bed rails were documented as not indicated. R13 was later observed with bilateral bed rails up, and the UM confirmed the rails were present on the hospice bed and stated there was no assessment of appropriateness or need when the hospice bed rails were implemented. For R29, the admission record showed diagnoses including stroke, hemiplegia and hemiparesis, epilepsy, muscle weakness, and respiratory failure, and the MDS showed severely impaired cognition with dependence for all mobility and ADLs. Admission nursing evaluations documented that R29 did not desire bed rails, was not using them, and that bed rails would not assist with turning or transfers; the entrapment review was not completed and bed rails were documented as not indicated. R29 was observed with bed rails up, and the UM stated she did not know he had them on the bed and that they may have been left from the last resident who used the bed. The DON and NDRM stated the assessment should have been completed when the bed with rails was received. For R190, the record showed diagnoses including multiple sclerosis, coordination problems, seizures, generalized muscle weakness, cognitive communication deficit, and major depressive disorder. The quarterly MDS showed a BIMS score of 15 and need for moderate help with rolling and sitting to standing. The quarterly nursing evaluation with side rail evaluation documented that R190 was not using side rails for positioning, support, or bed mobility, did not express a desire to use them, and that side rails were not indicated; however, the evaluation did not assess use of side rails or entrapment risk. R190 was observed with loose right-hand mid-bed side rails, and the ADON reviewed the evaluation and stated he should have had an assessment completed. For R204, the record showed paraplegia, and the quarterly MDS showed a BIMS score of 15, no upper or lower extremity impairments, and minimal help needed with rolling and lying to sitting. The quarterly nursing evaluation with side rail evaluation documented that R204 was not using side rails for positioning, support, or bed mobility, did not express a desire to use them, and that side rails were not indicated; however, the evaluation did not assess use of side rails or entrapment risk. R204 was observed with side rails in use on the bed, and the UM stated the procedure included completing an assessment, assessing restraint, signing consent, and assessing for entrapment. The ADON later reviewed the evaluation and stated the resident did not need side rails, while also acknowledging that the bars were physically the same as side rails and that there could still be a risk of entrapment.
Penalty
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Bed rails were used for three residents without the required documentation and authorization. One resident with hemiplegia and fluctuating decision-making capacity had bilateral half side rails in use, but RN and DON stated there was no current physician order or care plan for side rail use. Two other residents, including one with Alzheimer's disease and seizures and another with hemiplegia and intact cognition, had orders and assessments for 1/4 rails, but were observed or documented with 1/2 rails instead; the DSD and DON stated the specific 1/2 rail use lacked the proper order, informed consent, assessment, and care plan.
A resident with intracranial hemorrhage, respiratory failure, and hypertensive emergency was observed with all four bed rails raised, even though the physician's order and informed consent only addressed bilateral upper half side rails. Staff interviews confirmed the resident was being positioned with four side rails without a specific order or consent for that setup, and the facility policy required informed consent before bed rail use.
The facility failed to complete ongoing accurate assessments for bedrail use for two residents. One resident had weakness, a right BKA, and bilateral enabler bars, while another had CVA with left-sided paralysis and a left enabler bar. Both residents’ last Enabler/Assist Rail/Device Evaluation - V2 assessments were completed about a year earlier, and the ADON confirmed assessments should be done quarterly.
A resident with intact cognition and multiple serious diagnoses had half bedrails placed on both sides of his bed without a documented side rail assessment, informed consent, or evidence that alternatives were tried first. Staff interviews showed the Maintenance Supervisor was told to install the rails without being shown a signed consent, while RN and ADON staff were unaware the rails were in place or that the required documentation was missing. The resident stated he did not request the bedrails and was never spoken to about them.
A resident with severe cognitive impairment and a history of recent falls was repeatedly observed asleep in bed with bilateral upper grab rails elevated. The care plan, updated after the falls, included side rails as grab bars for fall prevention and assistance with repositioning, but the bed rail assessment documented that side rails or assist bars were not indicated, and no bed rail entrapment risk assessment was found. Staff interviews confirmed that the resident used the grab rails for turning and repositioning and that the care plan called for grab bars despite the assessment indicating otherwise, resulting in a deficiency for failing to ensure safe and properly assessed side rail use.
The facility failed to document alternative measures, risk-benefit discussion, and informed consent before side rail use for two residents. One resident with ESRD and severe cognitive impairment and another resident with dementia and intellectual disabilities were observed with side rails raised in bed, but records showed no current order for side rails and no documented evidence that alternatives were explored or that risks and benefits were reviewed with the resident or RP.
Bed rails used without required orders, consent, assessments, and care plans
Penalty
Summary
The facility failed to safely use bed rails for three sampled residents by not ensuring the required physician orders, informed consent, bed rail assessments, and care plans were in place for the specific bed rail use observed. The report states that the facility used bed rails without meeting its own criteria for use, and that staff and leadership acknowledged the need for a resident assessment, entrapment assessment, consent, physician order, and care plan before bed rails are used. Resident 11 was admitted with diagnoses including hemiplegia, hemiparesis following cerebral infarction, type II DM, and generalized muscle weakness. The H&P noted fluctuating capacity to understand and make decisions. The MDS showed the resident needed supervision or touching assistance with toileting, personal hygiene, showering, and lower body dressing, and was independent with rolling and sit-to-lying. During observation, the resident was seen in bed with bilateral side rails elevated, and CNA 4 stated the resident requested the side rails be elevated at all times. RN 5 reviewed the record and stated there was no current physician order for side rail use and no care plan documented for side rail use. The DON stated side rail use required assessment for risks and benefits, entrapment assessment, consent, a physician order, and inclusion in the comprehensive person-centered care plan. Resident 22 had diagnoses including Alzheimer's disease, contracture, and seizures, and the H&P stated the resident did not have capacity to understand and make decisions. The MDS indicated severely impaired cognition and dependence for mobility and ADLs. The OSR contained an order for padded side rails up times 2 top of quarter for mobility/enabler every shift for seizures, and the BRERO assessed quarter rails. However, during observation the resident's bed rails were identified as 1/2 length. The DSD stated the resident had an order for 1/4 padded side rails/bedrails but no order for the 1/2 bed rails actually in use, and that the BRERO and consent were for a 1/4 bed rail. Resident 163 had diagnoses including hemiplegia, hemiparesis following cerebral infarction, and disorders of bone density and structure of the left hand. The MDS showed intact cognition and dependence to partial assistance with mobility and ADLs. The OSR ordered may have 1/4 side rails up x 2 for mobility aid, and the BROA assessed bilateral 1/4 bedrails, but the DSD stated the resident was on 1/2 bed rails without a specific order, informed consent, bed rail assessment, or care plan for that use.
Failure to Obtain Consent and Order for Four Side Rails
Penalty
Summary
The facility failed to obtain consent and a physician's order for the use of four side rails for Resident 116. Resident 116 was admitted with diagnoses including nontraumatic intracranial hemorrhage, respiratory failure, and hypertensive emergency. The MD progress notes dated 7/9/2025 indicated the resident did not have the capacity to understand and make decisions. The physician's order dated 1/8/2026 directed bilateral upper half siderails up and locked when in bed for ADL changes, and the resident's informed consent dated 7/9/2025 also addressed bilateral upper half side rails up when in bed secondary to involuntary movement by gravity due to elevated head of bed for management and provision of enteral feeding. During observation on 4/20/2026, Resident 116 was seen in bed with upper and lower bed side rails raised on both sides, and later with the left and right upper side rails raised and the right lower side rail raised while CNA 3 stated the resident was supposed to have all four side rails raised up. DSD later stated the resident should only have upper side rails up per the physician's orders. ADON 1 reviewed the informed consent and stated there was no informed consent or physician's order for all four side rails, and that a specific informed consent and physician's order were required for four side rails. The facility policy stated bed rails are prohibited unless criteria are met and that informed consent must be obtained before using bed rails.
Failure to Reassess Bedrail Use and Risk
Penalty
Summary
The facility failed to conduct ongoing accurate assessments to ensure that bedrails were used to meet residents’ needs and to evaluate the risks associated with bedrail use for two residents. Facility policy titled Proper use of Bed Rails, dated 1/15/26, required resident assessment of risk from using bed rails, including risk of entrapment between the mattress and bed rail or in the bed rail itself, with reassessments at least quarterly, after a significant change in status, or when the type of bed, mattress, or rail changed. Resident R3 was admitted with diagnoses including high blood pressure, hyperlipidemia, and muscle weakness, and the care plan identified an ADL self-care deficit related to weakness/deconditioning and a right below-the-knee amputation, with bilateral enabler bars used to assist mobility. The last Enabler/Assist Rail/Device Evaluation - V2 assessment for R3 was completed on 4/11/25, yet bilateral enabler bars were observed on the bed during an observation on 4/13/26. Resident R7 was admitted with diagnoses including high blood pressure, hemiplegia, and CVA, and the care plan identified an ADL self-care deficit related to CVA with left-sided paralysis, with a physician order for a left enabler bar to assist with mobility and positioning. The last Enabler/Assist Rail/Device Evaluation - V2 assessment for R7 was also completed on 4/11/25, and a left enabler bar was observed on the bed during the same observation date. The ADON stated that enabler bar assessments should be done quarterly and confirmed the facility failed to conduct ongoing accurate assessments for these two residents.
Bedrails Installed Without Assessment or Informed Consent
Penalty
Summary
The facility failed to attempt alternatives before installing half bedrails on both sides of Resident #9's bed, failed to obtain informed consent before installation, and failed to ensure correct installation and maintenance of the bedrails. Record review showed that Resident #9 was a cognitively intact male with a BIMS score of 15 and diagnoses including type 2 diabetes mellitus, cerebrovascular accident, bilateral below-the-knee leg absence, and dependence on renal dialysis. His MDS did not address bedrail use, and his care plan addressed bed mobility assistance but did not reflect bedrails. The EHR also showed no side rail evaluation. Observation on 04/14/26 showed half bedrails on both sides of Resident #9's bed. The Maintenance Supervisor stated that the previous DON told him to place the bedrails on the resident's bed, but he was not shown a signed consent despite asking for it. He stated he understood consent was needed to show the resident had been evaluated and agreed to the bedrails, and he said he should have notified the Administrator before installing them when consent was not provided. He also stated he checks the rails weekly to ensure they are securely placed. Interviews showed staff were unaware of the bedrails or the required documentation. RN B stated she did not know Resident #9 had half bedrails and said she did not believe they were a restraint, though she acknowledged a resident could get an arm stuck and be hurt and that an assessment should be completed before bedrails are placed. ADON C stated Resident #9 should have had an assessment, care plan, and consent, and the DON stated residents with half bedrails should have a bedrail assessment, consent, care plan intervention, and nurse documentation. Resident #9 stated he did not request the bedrails, no staff spoke with him about them, and he was not given a consent or assessment. The facility policy stated alternatives should be attempted before installing bedrails and that assessment, informed consent, and proper installation and maintenance were required.
Inconsistent Bed Rail Assessment and Use After Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s use of side rails was consistent with the facility’s bed safety policy and the resident’s own assessments and care plan. The facility’s policy required the IDT to assess the resident’s sleeping environment, consider safety, medical conditions, comfort, freedom of movement, and input from the resident/family, and to use side rails only when needed to manage a medical symptom or to assist with repositioning or transfers when no other reasonable alternatives were identified. Surveyors observed the resident on multiple occasions lying in bed asleep with bilateral upper grab rails elevated. The resident’s MDS showed severe cognitive impairment, no impairment to upper or lower extremities, and a need for staff supervision for bed mobility. Progress notes documented that the resident was found on the floor on one occasion and kneeling on a floor mat on another occasion. Following these falls, the resident’s plan of care was updated with a problem addressing an actual fall, and the interventions included providing side rails to be used as grab bars. However, the resident’s Bed Rail Assessment dated the same month indicated that side rails or assist bars were not indicated for this resident, and there was no documentation of a bed rail entrapment risk assessment being conducted at that time. During interviews, a CNA confirmed that the resident used the grab rails to hold on when turning and repositioning, and an RN confirmed that the fall care plan interventions included grab bars while also verifying that the bed rail assessment showed grab rails were not indicated. This inconsistency between the care plan, the bed rail assessment, and the actual use of side rails led to the cited deficiency for failing to ensure the resident was free from accident hazards related to side rail use.
Failure to Document Alternatives, Risk-Benefit Discussion, and Informed Consent for Side Rail Use
Penalty
Summary
The facility failed to ensure that alternative measures were tried before side rails were used, and failed to document discussion of risks versus benefits and obtain informed consent for side rail use for two residents. The report states that these issues were identified for R3 and R6 during observation, interview, record review, and policy review. The deficiency involved side rail use without a current physician order and without the required documentation in the residents’ records. R3 was admitted with end stage renal disease and had a BIMS score of 3, indicating severe cognitive impairment. R3’s care plan listed upper side rails for mobility, and during observation R3 was resting in bed with the head of bed upright and side rails up on both sides. The side rail/entrapment evaluation for R3 showed no documentation that alternatives were explored before bed rail use, and there was no documentation of risks versus benefits or informed consent. The RNN stated the facility did not try alternatives before bedrail use for R3, did not discuss risks and benefits, and had nothing for the resident to sign for informed consent. R6 was admitted with mild intellectual disabilities and dementia and also had a BIMS score of 3. R6’s care plan included side rails up while in bed to aid in bed mobility and transfers, and during observation R6 was lying in bed with the head of bed elevated and bilateral half side rails raised. The side rail evaluation completed after the surveyor identified concern showed side rails were used, but the record contained no documented evidence of what alternatives were explored before implementation and no documented evidence that risks versus benefits were explained to the responsible party or that informed consent was obtained. The facility policy stated bedrails could be considered a form of physical restraint and that the need for bedrails should be identified in the resident assessment and plan of care.
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