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 dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
Failure to Obtain Informed Consent for Bed Rails: The facility did not review the risks and benefits of bed rails with the resident or representative and did not obtain informed consent before bed rails were installed for three residents. One cognitively intact resident with stroke-related weakness, one resident with dementia and severe cognitive impairment, and one resident with a BKA all had bed rails or mobility bars in place, but records and staff interviews showed missing or delayed consents and no clear evidence that the required information was provided before installation.
A resident with intact cognition, obesity, hypertensive heart disease, and muscle wasting used bilateral 1/4 bed rails as an enabler for bed mobility and positioning while requiring mechanical transfers with two staff. The care plan and physician orders authorized the rails and required quarterly nursing assessments to ensure safe, least-restrictive use, but no bed rail assessments were completed for two consecutive quarters. During observation, both rails were found in the up position and jammed, unable to be lowered by a CNA, and neither the CNA, an LVN, nor the DON were aware of the malfunction until the survey, despite a facility policy requiring proper installation, use per manufacturer instructions, and ongoing evaluation of bed rail safety.
A resident had a bed rail installed without a physician order, informed consent, or inclusion in the care plan. Staff interviews and record reviews confirmed that required assessments and documentation were not completed, despite facility policy mandating these steps for bed rail use.
A bed rail was used without first attempting alternative interventions, assessing the resident for safety risk, reviewing risks and benefits with the resident or representative, or obtaining informed consent. The facility also failed to ensure the bed rail was correctly installed and maintained.
A bed rail was used without first attempting alternative interventions, assessing the resident for safety risk, reviewing risks and benefits with the resident or representative, or obtaining informed consent. The facility also failed to ensure the bed rail was correctly installed and maintained.
A resident with multiple medical conditions was provided with bed rails for mobility without a documented assessment for entrapment risk or informed consent from the resident or representative. Staff interviews confirmed that required assessments and consents were not completed prior to installation, contrary to facility policy.
A bed rail was used without first attempting alternative interventions, assessing the resident for safety risks, reviewing risks and benefits with the resident or representative, obtaining informed consent, or ensuring proper installation and maintenance.
Two residents were provided bed rails or grab bars without proper assessment, documentation, or informed consent. For one resident with moderate cognitive impairment and a history of falls, grab bars were installed after a fall, but there was no physician's order, side rail assessment, or care plan addressing their use. Another resident with severe cognitive impairment and mobility needs had grab bars in use despite no documented assessment or consent. Staff interviews and record reviews confirmed that required procedures for bed rail use, as outlined in facility policy, were not followed.
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