Apart from considerations of resident comfort, there are a number of important legal aspects which have to be complied with before bed rails can be installed in a SNF environment. A clear link must exist between the restraint use and the benefit it provides to the resident in directly addressing a specific medical symptom. In other words, a resident’s medical symptoms must support the use of a bed rail or restraint, and must be documented in the appropriate medical record, ongoing assessments, and care plans. In addition, there must be a physician’s order permitting the use of the bed rail. This must state the specific medical symptom being treated by its use.
It is important for all SNF administrators to understand that the Centers for Medicare & Medicaid Services (CMS) will ultimately hold a facility accountable for the appropriateness of the use of any restraint, including that of a bed rail.
This raises the legal question: when is a bed rail considered a genuine restraint, and when is it not? And is there is a difference?
The answer to this is that any partial bed rail which assists an independent resident to enter and exit the bed independently is not considered a physical restraint—but anything else is. This means that the determination of bed rails as a restraint is based upon the ability of the resident to easily and voluntarily get in and out of bed when the equipment is in use. If the bed rail cannot be easily and voluntarily released, then it is considered to be a restraint. In this regard, it should be remembered that residents who are cognitively impaired are at a higher risk of entrapment or injury due to bed rails, and that serious injury from a fall is more likely from a bed equipped with bed rails.
The foremost legal requirement is for “informed consent.” The clinical record must show evidence of the resident’s or his/her representative’s informed consent for use of any physical restraint, including bed rails. This is most often done by obtaining a signature on a “restraint consent” box on an admission form or other documentation.
This consent form needs to include the following information:
– What assessed medical needs would be addressed by the use of bed rails
– The resident’s benefits from the use of bed rails and the likelihood of these benefits
– The resident’s risks from the use of bed rails and how these risks will be mitigated
– Alternatives attempted that failed to meet the resident’s needs, and alternatives considered but not attempted because they were considered to be inappropriate
The facility must maintain evidence that it provided sufficient information so that the resident or resident representative could make an informed decision. This evidence must be available for inspection on a “regular” basis by CMS—and there is no set definition of what constitutes “regular,” so managers should be prepared for inspections at any time.
Next: The Installation and Maintenance of Bed Rails
