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Side Rail Utilization Assessment: Decision-making Process for Resident Safety, Study notes of Nursing

Glasgow Caledonian University (GCU)Nursing

A comprehensive assessment form to help healthcare professionals determine the need for side rails for a resident based on their mobility, fall risk, and personal preference. The form includes sections for resident preference, fall/injury risk determination, mobility assessment, evaluation of alternatives, and other individual concerns.

Typology: Study notes

2021/2022

Uploaded on 09/12/2022

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Restraints: Side Rail Utilization Assessment
Complete this form as you go through the decision-making process of determining whether a side rail is
appropriate for a particular resident. Save it with the resident’s chart to document your decisions.
Resident Preference: Yes No Comments
Is resident able to state preference about side rails?
Has resident/legal surrogate requested side rails?
What type of side rail does resident/legal surrogate prefer? (circle choices) Full
Half
Quarter
1 rail
-or-
2 rails
Has resident/legal surrogate been informed about side rail risks and signed
statement of understanding?
Fall/Injury Risk Determination: Yes No Comments
Does resident have history of falls? — Any cause?
Does resident have a history of falls from the bed?
Does resident attempt to get out of bed by climbing over/around side rails?
Has resident ever sustained bruises, skin tears, lacerations or fractures from a
side rail?
Has resident ever become entangled in the side rail or entrapped between
the mattress and the side rail?
Is OT/PT and/or Maintenance assessment needed for equipment problems
(locks, side rail flush to mattress, other positioning aids)?
Mobility Assessment: Yes No Comments
Is resident immobile (comatose, paralyzed, no spontaneous movement)?
If primarily immobile, does the resident have enough mobility to turn or slide
to one side?
If mobile, does resident make any attempt to get out of bed?
If mobile, can resident get in/out of bed safely without any human assistance
or assistive device?
If mobile, is the resident at risk for orthostatic hypotension or does resident
have difficulty with balance/trunk control?
If mobile, does resident have decreased safety awareness due to confusion or
judgement problems?
Is OT/PT evaluation needed for transferring and/or ambulation skills?
Evaluation of Alternatives: Tried? Works?
Call bell (or bulb-type bell) in reach
Scheduled bathroom assistance at night
Decrease time in bed
Adapted from: Capezuti, E. (2000). Preventing falls and injuries while reducing side rail use. Annals of Long-Term Care, 8(6), 57-63.
continued >>
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Download Side Rail Utilization Assessment: Decision-making Process for Resident Safety and more Study notes Nursing in PDF only on Docsity!

Restraints: Side Rail Utilization Assessment

Complete this form as you go through the decision-making process of determining whether a side rail is

appropriate for a particular resident. Save it with the resident’s chart to document your decisions.

Resident Preference: Yes No Comments

Is resident able to state preference about side rails? Has resident/legal surrogate requested side rails? What type of side rail does resident/legal surrogate prefer? (circle choices) Full Half Quarter

1 rail -or 2 rails Has resident/legal surrogate been informed about side rail risks and signed statement of understanding?

Fall/Injury Risk Determination: Yes No Comments

Does resident have history of falls? — Any cause? Does resident have a history of falls from the bed? Does resident attempt to get out of bed by climbing over/around side rails?

Has resident ever sustained bruises, skin tears, lacerations or fractures from a side rail? Has resident ever become entangled in the side rail or entrapped between the mattress and the side rail? Is OT/PT and/or Maintenance assessment needed for equipment problems (locks, side rail flush to mattress, other positioning aids)?

Mobility Assessment: Yes No Comments

Is resident immobile (comatose, paralyzed, no spontaneous movement)? If primarily immobile, does the resident have enough mobility to turn or slide to one side? If mobile, does resident make any attempt to get out of bed? If mobile, can resident get in/out of bed safely without any human assistance or assistive device? If mobile, is the resident at risk for orthostatic hypotension or does resident have difficulty with balance/trunk control? If mobile, does resident have decreased safety awareness due to confusion or judgement problems? Is OT/PT evaluation needed for transferring and/or ambulation skills?

Evaluation of Alternatives: Tried? Works?

Call bell (or bulb-type bell) in reach Scheduled bathroom assistance at night Decrease time in bed

Adapted from: Capezuti, E. (2000). Preventing falls and injuries while reducing side rail use. Annals of Long-Term Care, 8(6), 57-63.

continued >>

Restraints: Side Rail Utilization Assessment (page 2)

Evaluation of Alternatives (continued): Tried? Works?

Increased frequency of monitoring Placement of assistive devices at bedside Restorative care to increase abilities to stand/walk Half or quarter rail for bed mobility/positioning or to enable transfer Pillows/cushions as bed boundary marker or curved mattress Bed alarm Low bed (top of mattress = 100-120% of lower leg length) High impact mat on floor beside bed Other (explain):

Other Individual Concerns: Use the following space to provide a detailed description of any other factors that would

be helpful in making a decision, especially regarding the resident’s response to side rails, feelings about removal of side rails, or other possible alternatives to side rail.

Side Rail Prevention/Reduction Committee Recommendations: Check boxes to indicate team’s decision.

No side rail is indicated because: (check one of the following options) Resident is immobile and makes no attempt to exit or shift in bed. Resident is able to safely enter and exit bed. Other interventions to prevent and/or reduce falls/injuries are currently in place: (list)

One full side rail is indicated to assist in bed mobility. (Circle one): Right Left Both full side rails are used, but are not a restraint, because resident is immobile. Both full side rails are used at resident/legal surrogate insistence. A waiver of responsibility has been signed. Both full side rails are the least restrictive device, based on resident physical and/or emotional needs. Half or quarter rail (circle one) will be used to assist in positioning and/or transfer.

Evaluator (signature/title): _____________________________________________________________ Date: ____________________

Resident/Legal Surrogate (signature): _____________________________________________________ Date: ___________________

Comments:

Resident: _____________________________________ Room: ___________________ Physician:_____________________________

Originally developed by Primaris, the Medicare Quality Improvement Organization for Missouri. This material was prepared by TMF Health Quality Institute, the Medicare Quality Improvement Organization for Texas, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 10 SOW-TX-C7- 11 - 24