SIDE -RAIL USE ASSESSMENT FORM



SIDE -RAIL USE ASSESSMENT FORM

Resident:________________________________ Room#:__________________

1. Is the resident Non-Ambulatory? YES NO

2. Does the resident’s level of consciousness fluctuate? YES NO

3. Does the resident have alteration in safety awareness due to cognitive (? YES NO

4. Does the resident have a history of falls? YES NO

5. Has the resident displayed poor bed mobility or difficulty moving to a YES NO

sitting position on the side of the bed?

6. Does the resident have difficulty with balance or poor trunk control? YES NO

7. Does the resident have difficulty with postural hypotension? YES NO

8. Is the resident on any meds which may require safety precautions? YES NO

9. Is the resident currently using the side rail for positioning or support? YES NO

10. Has the resident expressed a desire to have side rails raised while in bed for YES NO

safety and/or comfort?

11. Has the resident requested that the side rails not be released while sleeping? YES NO

12. Is the resident visually challenged? YES NO

INTERVENTIONS

⇨ 1. Lower the bed to the floor.

⇨ 2. Provide restorative care to enhance abilities to safely stand and walk.

⇨ 3. Provide frequent staff monitoring at night.

⇨ 4. Provide assisted toileting for the resident at night.

⇨ 5. Visual and verbal reminders to use the call bell.

⇨ 6. Other:

RECOMMENDATIONS: LEFT RIGHT BILATERAL NONE

( Side Rails are indicated and serve as an enabler to promote independence.

( The resident has expressed a desire to have side rails raised while in bed.

⇨ Side rails do not appear to be indicated at this time.

⇨ Side rails are indicated due to the following medical conditions/symptoms:__________________

The positive and negative aspects of side rail use have been discussed with the resident and/or family, and the resident and/or responsible parties are aware of the risks involved with side rail use.

_______________________ Date:__________________

Staff Signature

_______________________ Date:__________________

Resident Signature

_______________________ Date:__________________

Responsible Party Signature

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download