Based on observation, staff interview, record review, and facility policy review the facility failed to ensure the safety of a resident when bilateral side rails were applied to the middle of a residents' bed without assessing the resident for alternative safety methods, risk for entrapment, and failed to obtain informed consent prior to installation of bedrails for one (1) of three (3) residents reviewed. Resident #6. Findings include: A review of the facility policy titled, Side Rails, revised June 14, 2023, revealed Rationale: To provide guidelines for safe and effective use of bed rails in the patient care environment . An observation of Resident #6's room on 1/23/24 at 10:30 AM, revealed side rails in the up position bilaterally on each side of the bed. An observation of measurements taken of Resident #6's bed and side rails by the maintenance staff on 1/24/24 at 2:00 PM, revealed the bed mattress length measurement was 79 inches long. The length of the open space from the headboard to the top of the rail and bottom of the rail to the foot board measured 26 inches long respectively, and the side rails bilaterally measured 26 ½ inches long. The bed rails were bilaterally in the middle of the bed. An observation on 1/24/24 at 9:00 AM, revealed bilateral side rails up in the middle of Resident #6's bed, with a padding noted to top of the first bar of the side rail, with the two bars below observed to have no padding, and the two lateral bars on the side rails had no padding. Resident is observed sticking her arms into the side rails. A record review of the Skin Tear Report dated 10/9/23 for Resident #6 revealed, bleeding from right leg, three (3) skin tears noted two (2) cm (centimeters) x 0.5 cm, (1) one cm x (1) one cm moon shaped, and 0.2 cm x 0.2 cm. Blood was noted on the right side bed rail, orders to clean skin tears with normal saline (NS), pat dry, apply steri-strips, cover with telfa, wrap with gauze dressing. A record review of Skin Tear Report for Resident #6 dated 1/08/24, revealed CNA (Certified Nurse Assistant) reported when she entered room, resident had legs over the side of the head of the bed (HOB), blood was noted on the sheets, skin tear noted behind left knee .Resident has issues with skin tears due to fragile skin related to leukemia and trying to get out of the bed. A record review of the Skin Tear Report dated 1/23/24 for Resident #6, revealed CNA reported while getting resident dressed for bed she was hitting at staff and hit the bed rail, skin tear occurred, triangle in shape, two (2) cm on each side .skin tear to arm .they gently tried to remove her arm from side rail . An interview with Licensed Practical Nurse (LPN) #1 on 1/24/24 at 10:00 AM, she revealed she cares for Resident #6 often and revealed she often attempts to get out of the bed, resists care at times, and has hit her arms and legs on the side rails causing skin tears because she is so small, and her skin is thin and fragile. LPN #1 confirmed Resident #6 obtained a skin tear on 1/23/24 when she began hitting at staff and hit her right arm on the side rail causing a skin tear. An interview with CNA #2 on 1/24/24 at 10:20 AM, reported that Resident #6 is very active and always moving around. She confirmed she has observed Resident #6 with her legs and feet over the side rails and sometimes her hands and arms have been in between the the side rail bars. An interview with CNA #1 on 1/24/24 at 10:30 AM, revealed she has not cared for Resident #6 when she actually obtained a skin tear, but she has reported to multiple staff that the resident attempts to get out of bed throwing her arms and legs over the side rails. She has also had her arms between the bars on the side rails which she was able to easily remove without injuring the resident. An interview with the Director of Nursing (DON) on 1/24/24 at 11:00 AM, revealed she was unable to find any side rail assessments for safety, risk of entrapment, any alternative methods attempted prior to use of the side rails, or a consent for use of the side rails for Resident #6. She confirmed Resident# 6 has had multiple skin tears related to hitting her arms on the side rails. She confirmed after review of the Skin Tear Reports the reports dated 10/9/23 skin tears times three to right lower leg, 1/08/24 skin tear behind left knee, and 1/23/24 skin tear to right forearm were from Resident #6 hitting/bumping her extremities on the side rails. The DON then revealed the resident does have padding to the side rail to help prevent skin tears but confirmed the resident was still at risk for receiving skin tears because the entire side rail was not padded and confirmed the resident was at risk for entrapment in getting her arms and legs caught between the the rails and could possibly come over the rails and fall. Record review of the resident information form revealed the facility admitted Resident # 6 on 9/18/2023 with diagnoses including Unspecified Dementia, Unspecified severity without behavior/psych/mood, and Anxiety. Record review of the quarterly Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 12/25/23, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 99 which indicated that she was severely cognitively impaired. Section K revealed Resident #6 was 61 inches in height and weighed 98 pounds.