Failure to Ensure Safe and Appropriate Use of Side Rails
Summary
The facility failed to ensure the safe and appropriate use of side rails for three residents, leading to potential risks of entrapment and injury. For Resident 8, the facility did not conduct an assessment for the risk of entrapment or obtain informed consent before using side rails. The resident, who had advanced dementia and a history of falls, was observed with bilateral side rails raised and the bed positioned against a wall, restricting mobility and increasing the risk of entrapment. Interviews with staff and family confirmed that no assessment or informed consent was documented, and the facility lacked a policy on side rail use. Similarly, Resident 77, who had dementia and was at high risk for falls, was found with the bed pushed against the wall and both upper side rails raised. There was no physician's order for the use of side rails, and the staff confirmed that the side rails were used to prevent falls without conducting a risk assessment or obtaining informed consent. The DON acknowledged the need for assessments and consents for side rail use and the requirement for a physician's order. Resident 70, diagnosed with Alzheimer's disease and dementia, was also found with the bed pushed against the wall and both upper side rails raised. The resident's care plan indicated a high risk for falls, but there was no physician's order for side rail use. Staff confirmed that the side rails were used to prevent falls without conducting a risk assessment or obtaining informed consent. The DON reiterated the importance of assessing the risk of injury from entrapment and obtaining consent for side rail use.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Surveyors determined that the facility failed to assess multiple residents for the appropriateness of bed rail use before installing bed rails on their beds. Observation with the DON revealed numerous residents with bed rails in place, and the DON confirmed that no prior safety risk assessments or evaluations of less restrictive alternatives had been completed, despite a written policy requiring such assessments and documentation before bed rails are used.
A resident with significant mobility and medical needs was injured when a bed rail detached during in-bed care, causing a fall and a displaced upper arm fracture. Staff interviews and documentation revealed the bed rails had been installed incorrectly on the bed frame, were previously reported as loose, and were not compatible with the bed's crossbar. The facility lacked the correct user manual for the bed rails, and staff had previously adjusted the rails improperly, leading to the incident.
A facility failed to properly assess and document the risks of bed rail entrapment for residents using alternating pressure mattresses, leading to a resident's death by asphyxia after becoming wedged between the mattress and bed rail. The facility did not measure mattress gaps under compression, did not document medical need or alternatives to bed rails, and did not attempt alternative interventions before installing side rails for multiple residents, placing several at risk for harm.
A facility failed to assess a resident for entrapment risks before installing bed rails, despite the resident's medical conditions such as hemiplegia and seizures. The resident's care plan included bed rails due to fall risk, but no assessment was documented. The facility's policy requires such assessments, which were not conducted.
A facility failed to assess and document the need for bed rails for a resident receiving hospice care. Despite the use of bed rails being noted in a consent form, there were no physician orders or assessments, and the form lacked necessary signatures. Observations confirmed the use of bed rails, but they were not coded in the MDS assessments. The facility's policy required assessments and evaluations that were not completed, leading to the deficiency.
The facility failed to assess and obtain consents or orders for bed rail use for six residents, despite their need for extensive ADL assistance. The facility's policy requires assessments and informed consent, but these were not documented. The DON confirmed the absence of necessary records, indicating a systemic compliance failure.
Failure to Assess Residents Prior to Bed Rail Use
Penalty
Summary
Surveyors found that the facility failed to assess residents for the use of bed rails prior to their application, contrary to the facility’s own policy. Observation conducted with the Director of Nursing (DON) showed that 19 identified residents had bed rails on their beds, and the DON confirmed that these residents had not been assessed for the appropriateness of bed rail use before the rails were applied. The facility’s written policy, dated 02/05/26, states that staff will assess residents for the appropriateness of bed rails prior to use and will attempt and document less restrictive measures before implementing bed rails. Despite this policy, the required safety risk assessments and consideration of less restrictive alternatives were not completed or documented for any of the 19 residents observed with bed rails in place. This deficiency affected 19 residents reviewed for bed rails out of a total facility census of 107 residents. The DON’s interview corroborated the observation findings and confirmed noncompliance with the facility’s policy regarding pre-use assessment of bed rails and documentation of attempts at less restrictive measures.
Improper Bed Rail Installation Resulting in Resident Injury
Penalty
Summary
The facility failed to ensure that bed rails were properly installed and maintained, resulting in actual harm to a resident. The resident, who had multiple complex medical conditions including a recent traumatic amputation, diabetes with polyneuropathy, COPD, pulmonary hypertension, and an activities of daily living (ADL) self-care deficit, required maximum assistance from staff for bed mobility and personal care. Documentation indicated that the resident expressed a desire for bed rails to assist with autonomy, and bilateral bed rails were provided. However, the Minimum Data Set assessment did not indicate bed rail use, and there was no evidence that the bed rails were consistently or correctly installed according to manufacturer instructions. On the day of the incident, three staff members were providing in-bed care when the resident was rolled to the side and the bed rail detached from the bed frame. The staff attempted to lower the resident to the floor, but the resident sustained a displaced fracture of the right humeral neck. Staff statements and interviews confirmed that the resident was holding onto the bed rail when it broke off, and that the bed rail had been previously reported as loose and had been moved to an insecure location on the bed frame. The Maintenance Director confirmed that the bed rails were not compatible with the crossbar where they had been attached, and that staff had previously adjusted and installed the bed rails incorrectly. The facility did not have the correct user manual for the bed rails in use, and the manual provided to surveyors did not match the equipment used. Facility policy required that bed rails be installed and maintained according to manufacturer specifications, including ensuring compatibility with the bed and mattress, and regular inspection for secure installation. Despite these requirements, the bed rails were not properly installed or maintained, and staff were not able to identify who had moved or adjusted the rails prior to the incident. This failure directly resulted in the resident's fall and injury during routine care.
Failure to Assess and Mitigate Bed Rail Entrapment Risks Results in Resident Death and Immediate Jeopardy
Penalty
Summary
The facility failed to thoroughly assess residents for the risk of entrapment when utilizing bed rails, particularly when used in combination with alternating pressure mattresses (APMs). The assessment process did not include compressing the APM to measure the potential gap between the mattress and the side rail, nor did it address the medical needs to be met by bed rail use, the risks associated with bed rails and how these would be mitigated, or alternatives that were attempted or considered. Documentation was lacking regarding any attempts to use alternatives prior to installing side rails for multiple residents. The Siderail Safety Questionnaire used by the facility did not capture these critical elements, and there was no evidence in the medical records that these assessments or considerations were made for the residents reviewed. One resident, who was severely cognitively impaired, dependent on staff for activities of daily living, and required a mechanical lift for transfers, was found deceased with his head wedged between the APM and the right-side grab bar rail, and his lower body on the floor mat next to the bed. The coroner determined the cause of death to be asphyxia due to neck compression from being wedged between the safety rail and mattress. Observations of the bed after the incident revealed significant gaps between the compressed APM and the side rail, which were not accounted for in the facility's assessment process. The facility's practice was to measure gaps only when the resident was lying on the bed, not when the bed was unoccupied or when the mattress was compressed, leading to unrecognized hazards. Additional residents were also found to be at risk due to similar failures in assessment and documentation. For each of these residents, there was no evidence that alternatives to side rails were attempted or considered, and the Siderail Safety Questionnaire did not include required information about medical needs, risk mitigation, or alternative interventions. Observations and interviews confirmed that gaps between the APM and side rails exceeded safe limits when the mattress was compressed, and staff were unaware of the need to assess these conditions. These deficiencies resulted in Immediate Jeopardy and serious harm, including death for one resident, and placed others at risk for entrapment.
Failure to Assess Bed Rail Risks for a Resident
Penalty
Summary
The facility failed to assess a resident for the risks of entrapment associated with the use of bed rails prior to their installation or use. This deficiency affected one resident out of seven who had orders for bed rails. The resident, who was admitted with diagnoses including hemiplegia, hemiparesis, cerebrovascular disease, stroke, muscle weakness, and seizures, had no documented assessment for bed rail use in their medical record. Although there was a signed consent form for bed rails, the facility did not conduct a proper risk assessment as required by their policy. The resident's quarterly Minimum Data Set (MDS) assessment indicated intact cognition and a need for substantial to maximum assistance with bed mobility, toileting, hygiene, and transfers, but did not identify bed rails as a restraint. The care plan noted the resident was at risk of falls and had seizures, with interventions including the use of bilateral half-size bed rails. Despite these interventions, the facility's MDS nurse confirmed that no assessment for bed rail use had been conducted for the resident. The facility's policy mandates an assessment for entrapment risks and informed consent prior to bed rail installation, which was not followed in this case.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to assess the need for bed rails for a resident, identified as Resident #21, who was admitted to the facility and began receiving hospice services. The resident had multiple diagnoses, including Alzheimer's disease and dementia, and was under the care of a medical Power of Attorney (POA), their daughter. Despite the use of bed rails being documented in a consent form, there was no indication of the purpose, release schedule, or physician orders for the bed rails. Additionally, the consent form lacked signatures from the POA or a physician. The resident's care plans included the use of bed rails for bed mobility, but no physician orders or assessments for bed rails were found in the medical records. Observations and interviews revealed that the bed rails were in use, but the facility's documentation did not reflect this. A State tested Nurse Aide confirmed the use of bed rails during care, and a Quality Assurance Nurse verified that the bed rails were not coded in the Minimum Data Set (MDS) assessments. The facility's policy on bed safety and bed rails required specific criteria to be met before their use, including resident assessment and interdisciplinary team evaluation, which were not completed for this resident. The lack of proper assessment and documentation led to the deficiency identified by the surveyors.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to properly assess and obtain consents or orders for the use of bed rails for six residents. These residents, identified as #27, #34, #36, #190, #194, and #196, were all reviewed for bed rail use. The facility's policy requires an individualized nursing observation upon admission, quarterly, and as needed, to address the need for a safety device, medical symptoms for use of the device, and whether the device restricts movement. However, the facility did not complete these assessments or obtain informed consent for the use of bed rails for the residents in question. The medical records of the residents revealed that they required extensive assistance for activities of daily living (ADL), with some residents being cognitively intact and others having severe cognitive impairment. Despite these needs, there were no documented bed rail assessments, informed consents, or physician orders for the use of bed rails. The Director of Nursing confirmed during interviews that the necessary assessments and consents were not present in the electronic health records, indicating a systemic failure to comply with the facility's policy on restraint/enabler use.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
