F700 (Bedrails) is one of 17 discrete F-Tags now included under Section 483.25, Quality of Care, in Title 42 of the Code of Federal Regulations. These tags are among the indicators of substandard quality of care, meaning even a single deficiency with a scope/severity level of F, H, I, J, K, or L could potentially trigger an extended survey. Some recent standard surveys under the new Long-term Care Survey Process (LTCSP) indicate that providers may want to review their compliance in this area.
The new F700 tag has new corresponding interpretive guidance in Appendix PP of the State Operations Manual. The Key Elements for Noncompliance for F700 are as follows:
To cite deficient practice at F700, the surveyor's investigation will generally show that the facility failed to do one or more of the following:
· Identify and use appropriate alternative(s) prior to installing a bedrail;
· Assess the resident for risk of entrapment prior to installing a bedrail;
· Assess the risk versus benefits of using a bedrail and review them with the resident or if applicable, the resident’s representative;
· Obtain informed consent for the installation and use of bedrails prior to the installation.
· Ensure appropriate dimensions of the bed, based on the resident’s size and weight;
· Ensure correct installation of bedrails, including adherence to manufacturer’s recommendations and/or specifications;
· Ensure correct use of an installed bed or side rail; and/or
· Ensure scheduled maintenance of any bedrail in use according to manufacturer’s recommendations and specifications.
While the F700 guidance lays out a comprehensive roadmap that enables providers to meet these requirements, the revised definition for what counts as a bedrail may be a sticking point for some facilities, suggests Theresa Poole, RN, vice president of clinical services for Christian Horizons in St. Louis, MO, which at press time has experienced surveys at three facilities in two states.
“Many providers may not be totally prepared for the change in how grab bars and assist bars are defined,” explains Poole. “They now need to be treated just like any other bedrail.”
Here is the definition of bedrails set forth in the F700 guidance:
“bedrails” are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths. Also, some bedrails are not designed as part of the bed by the manufacturer and may be installed on or used along the side of a bed. Examples of bedrails include, but are not limited to:
· Side rails, bed side rails, and safety rails; and
· Grab bars and assist bars.
“The interdisciplinary team must have the appropriate assessments and consents in place in relation to grab and assist bars,” says Poole. “In the new survey process, surveyors will write up facilities that haven’t done this.” Note: The F700 guidance details some components of the assessment that the interdisciplinary team must consider when determining whether to use bedrails to meet the needs of the resident, as well as potential risk factors to consider when assessing the resident’s risk from using bedrails.
The F700 guidance includes an investigative protocol for surveyors to use to assess bedrail use. (See the protocol at the end of this article.) This investigative protocol mirrors a Critical Element Pathway, guiding surveyors to obtain information using resident observations, resident or resident representative interviews, staff interviews, and record reviews, including a care plan review.
In addition, two Critical Element Pathways also address F700:
· Physical Restraints Critical Element Pathway (form CMS-20077) includes F700 as one of 11 other tags, care areas, and facility tasks for surveyors to consider.
· Accidents Critical Element Pathway (form CMS-20127) includes F700 as the second of nine Critical Element Decisions for surveyors to specifically make to determine whether a citation is needed:
2) Based on observations, interviews, and record review, did the facility assess each resident for risk of entrapment and only use bedrails after trying other alternatives and explaining the risks and benefits to the resident or the resident’s representative?
If No, cite F700
NA, bedrails were not investigated.
The other eight Critical Element Decisions in the Accidents Critical Element Pathway guide surveyors through the decision-making for eight additional tags. “So there’s a strong possibility that if you are tagged for F700, you will receive additional tags as well,” explains Poole. “For example, if the survey team cites F700, there’s a good chance they will also cite F909 (Resident Bed), as well as a care planning tag such as F656 (Develop/Implement Comprehensive Care Plan) or F657 (Care Plan Timing and Revision).”
Note: In addition to providing bedrail installation and maintenance action steps designed to prevent deaths and injuries from entrapment and/or falls, the F700 interpretive guidance also refers surveyors to F909 for guidance about inspection and maintenance issues related to bedrails.
This dual emphasis on mechanical safety and resident assessment means that “your maintenance department should work as part of your interdisciplinary team to make your bed safety program as robust as possible,” stresses Poole.
F700 (bedrails) investigative protocol (§483.25(n))
Note: The following F700 investigative protocol excerpted from Appendix PP of the State Operations Manual tells surveyors when to use the protocol and what information they should obtain via resident observations, resident or resident representative interviews, staff interviews, and record reviews, including a care plan review, in order to make a determination about facility compliance, so it can be used as a facility audit tool.
Use this protocol for:
· A sampled resident who has MDS data that indicates a bed/side rail is used;
· Surveyor observation of the use of a bed/side rail for a resident; and/or
· An allegation of inappropriate use of a bed/side rail received by the State Survey Agency.
Briefly review the assessment, care plan, and orders of the resident to identify facility interventions and to guide observations to be made. Corroborate observations by interview and record review.
During observations of a resident who has bed/side rails, determine:
· What type of bedrail is installed and for how long the bedrail has been in use;
· If the bedrail in good working order;
· Frequency of use of the bedrail;
· Any physical or psychosocial reaction to the bedrail, such as attempts to release/remove the bedrail, verbalizing anger/anxiety;
· Who applies the bedrail and how often monitoring is provided;
· How the resident is positioned in the bed relative to the bedrails and how the resident moves in bed;
· How the resident requests staff assistance (e.g., access to the call light);
· Whether the resident is toileted, ambulated or provided exercises or range of motion when the bedrails are released, who released the bedrails and for how long;
NOTE: A resident may have a device in place that the facility has stated can be removed by the resident. For safety reasons, do not request that the resident remove the bedrails, but rather request that staff ask the resident to demonstrate how he/she releases the bedrails.
Interview-Resident or Resident Representative
Interview the resident, or if applicable, the resident representative, to the degree possible to identify:
· Who requested the bedrail to be installed,
· Prior to the use of the bedrail, whether staff provided information regarding how the bedrail would address a resident need, the risks and/or benefits, and alternatives to bedrails, when and how long the bedrails were going to be used;
· Whether the interdisciplinary team provided interventions for monitoring and release of the bedrails for activities, such as use of the bathroom, walking and range of motion;
· Whether staff discussed mobility issues with the resident, or resident’s representative, when the bedrail is in use and/or other impacts on activities of daily living and involvement in activities; and
· How the resident can request staff assistance when the bedrail is in use.
Interview direct care and licensed nursing staff on various shifts who provide care to the resident to determine:
· Knowledge of specific interventions related to the use of the bedrails for the resident, including:
o When use of the bedrail was initiated;
o The rationale for selecting the bedrail for use;
o Identifying the benefits and risks of using the bedrail;
· What is the resident’s functional ability, such as bed mobility and ability to transfer between positions, to and from bed or chair, to toilet and to ability to stand;
· Whether there have been any physical and/or psychosocial changes related to the use of the bedrail, such as increased incontinence, decline in ADLs or ROM, increased confusion, agitation, and depression;
· Whether other interventions have been attempted to minimize or eliminate the use of the bedrails; and
· Whether there are facility guidelines/protocols for the use of bedrails.
Interview the charge nurse, to gather the following additional information:
· How the implementation of the use of bedrails is monitored and who is responsible for the monitoring;
· Who evaluates and assesses the resident to determine the ongoing need for bedrails;
· Whether bedrail use should be gradually decreased; and
· How the modifications for the interventions are evaluated for effectiveness in discontinuing the use of the bedrails.
Review the MDS, assessments, physician orders, therapy and nursing notes and other progress notes that may have assessment information related to use of the bedrail. Determine whether identified decline can be attributed to a disease progression or use of bedrails. Determine whether the assessment information accurately and comprehensively reflects the status of the resident for:
· The identification of specific medical symptom(s) for which the bedrail is used;
· Functional ability, including strength and balance (such as bed mobility and ability to transfer between positions, to and from bed or chair, and to stand and the ability to toilet);
· Identification of the resident’s risks such as physical/functional decline and psychosocial changes, and benefits, if any, due to the use of the bedrails;
· Attempts at using alternatives to bedrails, including how the alternatives did not meet the resident’s medical or safety need or were inappropriate;
· Identification of any injuries, or potential injuries, that occurred during the use of bedrails.
When the interdisciplinary team has determined that a resident may benefit from the use of a device for mobility or transfer, whether the assessment includes a review of the resident’s:
· Bed mobility; and
· Ability to transfer between positions, to and from bed or chair, to stand and the ability to toilet.
Review the resident’s care plan to determine if it is consistent with the resident’s specific conditions, risks, needs, behaviors, preferences, current professional standards of practice, and included measurable objectives and timetables, with specific interventions/services for use of the bedrail. The care plan may include:
· Which medical need would be met through the use of bedrails;
· How often the bedrail is applied, duration of use, and the circumstances for when it is to be used;
· How monitoring is provided, and when and how often the bedrail is to be released and assistance provided for use of the bathroom, walking and range of motion;
· What the resident’s functional ability is, such as bed mobility and ability to transfer between positions, to and from bed or chair, and to stand and toilet and staff required for each function that requires assistance;
· Identification of interventions to address any potential complications such as physical and/or psychosocial changes related to the use of the bedrails, such as increased incontinence, decline in ADLs or ROM, increased confusion, agitation, and depression;
· Identification of interventions to minimize or eliminate the use of the bedrails; and
· Who monitors for the implementation of the use of the bedrails, and who evaluates and assesses the resident to determine the ongoing need for bedrails, whether the bedrail use should be gradually decreased, and how the modifications for the interventions are evaluated for effectiveness in discontinuing the use of the bedrail.
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