Last week, we published Part 1 of our “Ftag of the Week” for F700 Bed Rails. Bed rails have been making news headlines again recently, and oftentimes, when we see issues in the news, we see those same areas get more attention on survey. In our previous post, we laid out the provider’s responsibilities for the use of bed rails. Now let’s discuss what happens after a facility has attempted alternatives to bed rails, but the alternatives did not meet the resident’s needs. First, we will review components of the resident assessment, as well as the information that needs to be provided so the resident/ representative can make an informed decision about the use of bed rails and provide consent for use.
Assessment
As mentioned above, it is required that alternatives to bed rails are attempted prior to a decision to use bed rails. Once the attempted alternatives have been tried and failed, then the facility needs to assess the resident for entrapment risk and possible benefits to use. The Interpretive Guidance (IG) includes a list of components that must be considered when determining if bed rails can meet the needs of a resident. These include:
- Evaluation of alternatives to use of a bed rail that were attempted and how these alternatives failed to meet the resident’s assessed needs
- Medical diagnosis/ conditions/ symptoms (including behavioral symptoms)
- Underlying medical conditions
- Medications
- Cognition
- Existence of delirium
- Communication
- Sleep habits
- Size and weight
- Mobility in and out of bed
- Risk of falling
- Ability to self-toilet safely
- Acute medical/ surgical interventions
- Assessment of the resident’s risk from using bedrails
The April 2013 FDA “Hospital Bed Safety Workgroup Clinical Guidance For the Assessment and Implementation of Bed Rails in Hospitals, Long-Term Care Facilities, and Home Care Settings” was used to modify the resident’s risk assessment and guides surveyors to review several key areas. These include:
- Accident hazards
Immediate Jeopardy Survey Citation – F700 S/S: J (Standard)
A facility was placed in Immediate Jeopardy for failure to assess residents for the risk of entrapment from half bed rails prior to installation to ensure they were safely applied and that physicians’ orders were obtained for use. A resident’s head and neck became wedged between the half bed rail and mattress with her legs at a kneeling position on the floor, resulting in respiratory distress. Two additional residents were identified to be at risk for potential entrapment between the rail and mattress because of an excessive gap between the two areas.
- Barrier to residents safely getting out of bed
Survey Citation – F700 S/S: D (Complaint)
A facility failed to maintain bed rail safety for one resident, as well as follow its own Side Rail policy when a resident had an unwitnessed fall from bed that resulted in multiple skin tears and the resident being sent to the hospital for evaluation. Review of the Incident report found that a CNA went into the resident’s room and found the resident holding onto the side rail, laying on the floor. The resident stated that he/she was trying to get to the door and get out of the room. There was no documentation that the resident/representative were provided with education regarding the use of bed rails.
- Physical Restraint
Actual Harm Survey Citation – F700 S/S: G (Complaint)
A facility was cited for failure to accurately assess the use of side rails, failure to identify a medical symptom for the use of a restraint and failure to obtain consent for the use of side rails for a cognitively impaired resident. The resident became entangled in the side rails, which resulted in a broken arm. Review of the resident record lacked documentation that interventions prior to side rails were attempted. Review of the side rails assessment showed that the resident had a history of falls, was able to get out of bed without assistance and was able to express choice about side rail use, despite being severely cognitively impaired. It was also noted that the use of side rails would keep the resident from voluntarily getting out of bed.
Other areas that need to be assessed include:
- Potential negative physical outcomes, including decline in resident function, skin integrity issues, and/or decline in other ADLs
- Potential negative psychosocial outcomes, including creation of agitation or anxiety, contributing to the resident’s feeling of isolation, or creating an undignified self-image that could impact the resident’s self-esteem
Informed Consent
After alternatives to bed rails have been attempted and the resident has been assessed for use of bed rails, the facility still has more work to do. The facility is required to obtain informed consent from the resident/ resident representative by providing sufficient information for the individual to make a decision. This information must include the potential risks and benefits and must be maintained by the facility. Areas that need to be included in information provided include:
- The assessed medical needs that would be addressed by the use of bed rails
- Resident’s benefits of use of bed rails and the likelihood of these benefits
- Resident’s risks of use of bed rails and how these risks will be mitigated by the facility
- Alternatives attempted that failed to meet the resident’s needs
- Alternatives considered by not attempted because they were considered inappropriate for the resident
Survey Citation – F700 S/S: E (Standard/Complaint)
A facility was cited for failure to ensure that multiple residents using bed rails had consented to their use prior to the installation of bed rails. On interview, the Director of Nursing stated that the facility did not have a document used to assess the rails for each resident, and did not have a consent form for the use of side rails. Instead, on admission, residents were assessed for the need for side rails, and the staff discussed the need to have side rails during morning report daily. Further interview with staff identified that every bed in the facility had side rails and that no information was provided in the admission packet about side rails.
In Part 3 of CMSCG’s “Ftag of the Week” for F700 Bed Rails, we will review what happens once the resident has been appropriately assessed and informed consent has been provided. At that point, the facility will actually be able to install bed rails – but then they also need to be maintained and the use of bed rails monitored and supervised.
