SIDE RAIL EVALUATION
SIDE RAIL EVALUATION
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|RESIDENT: |ROOM #: |DATE: |
|SIGNATURE OF STAFF PERSON |
|COMPLETING FORM: |
|COGNITION |
|Resident’s cognitive status (check all that apply): |
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|( ALERT ( CONFUSED ( ORIENTED ( SAFETY IMPAIRED ( POOR LONG-TERM MEMORY |
|( POOR SHORT-TERM MEMORY |
|( YES ( NO THE RESIDENT IS ABLE TO FOLLOW DIRECTIONS |
|( YES ( NO THE RESIDENT IS ABLE TO RETAIN SAFETY INFORMATION |
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|( YES ( NO BED RAILS ARE CURRENTLY USED |
|if yes, please explain: |
| |
|PHYSICAL ABILITIES |
|( YES ( NO THE RESIDENT IS PHYSICALLY ABLE TO RELEASE RAILS |
|( YES ( NO THE RESIDENT USES THE RAILS TO ENHANCE BED MOBILITY |
|( YES ( NO THE RESIDENT HAS A HISTORY OF PAST RAIL USE |
|( YES ( NO THE RESIDENT CAN VOLUNTARILY MOVE BODY |
|( YES ( NO THE RESIDENT EXPERIENCES INVOLUNTARY MOVEMENTS |
|if yes, please explain: |
|RESIDENT TRANSFER STATUS: |
|OTHER INTERVENTIONS THAT HAVE BEEN TRIED: |
|( LOW BED ( WEDGE ( LIPPED MATTRESS ( TRAPEZE ( TRANSFER BAR ( TRANSFER POLE |
|( PERSONAL SAFETY ALARM ( BED ALARM ( FLOOR PAD ( COMMODE AT BEDSIDE |
|( TOILETING PROGRAM ( OTHER: |
|BED CONFIGURATION |
|RESIDENT HEIGHT: |RESIDENT WEIGHT: |MATTRESS/BED SIZE: |
|TYPE OF RAIL REQUESTED: * if rail does not fit bed/mattress, do not place rail(s). |
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|INTERDISCIPLINARY TEAM |
|REASON FOR RECOMMENDATION: |
|( SAFETY CONCERNS ( ASSIST WITH BED MOBILITY ( ASSIST WITH TRANSFERS |
|( OTHER: |
|RESIDENT/FAMILY |
|( YES ( NO THE RESIDENT/FAMILY UNDERSTANDS THE RISKS OF BED RAIL USE |
|( YES ( NO THE RESIDENT/FAMILY REQUESTED THE USE OF BED RAILS |
|if yes, please provide reason for their request: |
|( SAFETY ( FEAR OF FALLING ( FEAR OF INJURY ( WANDERING ( ILLNESS |
|( INCREASED BED MOBILITY ( INCREASED INDEPENDENCE ( OTHER: |
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|* all reasons are also included in the care plan |
|LIST ALL RISKS/BENEFITS OF BED RAIL USE: |
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|( YES ( NO THE BED RAIL USE IMPEDES THE RESIDENT’S FREEDOM OF MOVEMENT |
|( YES ( NO THE BED RAIL PRECLUDES THE RESIDENT’S ACCESS TO HIS/HER BODY |
This facility must justify the need for bed rail use (full, ½, ¼, etc.) and when the bed rail(s) will be used (only at night, at all times when in bed, only with an illness, etc.). This information must be entered into the care plan and re-evaluated after every occurrence, change of condition, and quarterly.
There must be informed consent signed for use of restraints. This facility will ensure that the resident/family is aware of the risks (strangulation, broken bones, immobility, pressure sores, dehydration, incontinence, agitation, muscle atrophy, loss of independence, visual obstruction are examples).
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