Resident Bed Rail Consent Form - Michigan printable pdf download

Resident Bed Rail Consent Form - Michigan

MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS

BUREAU OF HEALTH CARE SERVICES

LONG TERM CARE DIVISION

RESIDENT BED RAIL CONSENT FORM

(Per Michigan PA 437 of 2000, January 9, 2001, amending Michigan Public Health Code, PA 368 of 1968)

Resident Name: ________________________________ Date of Request: ___________________

(Last, First, MI)

PART 1

Please initial one of the following blocks indicating the person requesting the use of bed rails.

○

This request was prepared by the above named resident while being mentally capable of participation in

his/her own health care decisions.

○

This request was prepared by the resident’s legally appointed and appropriately empowered attorney-in fact,

as the resident has been determined to be incapable of participating in his/her own health care decisions by a

team of physicians in a written Medical Determination.

○

The resident’s Probate Court appointed guardian prepared this request.

Surrogate’s Name: _____________________________________

○ Attorney-in-Fact

○ Guardian

(Last, First, MI)

PART 2

I am responsible for the medical treatment decision of the above named resident. I have been advised that I may

request that bed rails be installed on the resident’s bed. The risk and alternatives to using bed rails, as they apply to

this resident’s particular condition and circumstances, have been clearly explained to me.

I understand that, in addition to this signed consent form authorizing the use of bed rails for this resident, a written

order from the resident’s attending physician, specifying the medical rational and circumstances for use, must be

obtained prior to the installation of this medical treatment device.

It is also my understanding that the Facility will periodically review and re-evaluate the resident’s need for bed rails

and that the resident, responsible party and attending physician will be consulted in this matter.

With all of the above information in mind, I consent to the installation and utilization of bed rails for the care of the

above named resident, consistent with the written orders of the attending physician. I understand that this

authorization is revocable, except to the extent of those actions already taken.

Signature: ________________________________________________ Date: ________________

(Resident, Attorney-in fact, or Guardian)

Witness Signature: _________________________________________ Date: ________________

Authority: P.A. 368 of 1978 as amended

The Michigan Department of Licensing and Regulatory Affairs will not discriminate against any individual or group

Completion: Mandatory

because of race, sex, religion, age, national origin, color, marital status, disability, or political beliefs. You may

BHCS-LTC-104 (Rev. 01/09/13)

make your needs known to this Agency under the Americans with Disabilities Act if you need assistance with

reading, writing, hearing, etc.

Resident Bed Rail Consent Form - Michigan

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