Failure to Ensure Bed Rail Safety Leads to Resident Death
Summary
The facility failed to ensure the correct installation, use, and maintenance of bed rails, leading to a significant safety risk for 55 residents. Specifically, the facility did not inspect and regularly check the mattress and bed rail for areas of possible entrapment. This oversight was evident in the case of a resident with a contour mattress and a right side bed rail, where the facility did not evaluate alternatives to bed rails, review the risks and benefits with the resident or their representative, or obtain informed consent prior to the installation of bed rails. The deficiency was highlighted by a tragic incident involving a resident diagnosed with Alzheimer's disease, who was found with their head wedged between the bed rail and the mattress, resulting in their death. The resident was last observed at approximately 4:30 AM for incontinence care, and at 5:45 AM, they were found in a kneeling position beside the bed, with no pulse or respirations. The cause of death was listed as probable positional asphyxiation. Interviews with facility staff revealed a lack of familiarity with guidelines for the prevention of bed entrapment and an absence of specific measurements regarding entrapment risk zones. Maintenance staff were responsible for installing bed rails and performing bed safety checks, but they did not have a process for measuring entrapment risk zones. The facility's policy did not include entrapment guidelines, and there was no documented evidence that beds were measured for entrapment risk, putting residents at risk for serious injury or death.
Removal Plan
- Maintenance was trained on entrapment zones and how to measure per FDA guidelines.
- An audit tool that contained all aspects of bed safety, compatibility of bed, mattress, and bed rails; mattress inspection, and entrapment zones was completed for all beds in the facility.
- The updated bed rail policy and procedure was provided which included Maintenance will check the bed model and install a compatible bed rail. Once installed the bed will be checked prior to use for entrapment zones, and if any are determined to be non-compliant the device will be un-installed immediately and nursing will be informed. Maintenance will close out the work order ticket once completed and update nursing of completion. Staff education was completed.
- A bed rail process and procedure audit tool was developed to monitor alternatives tried, bed rail assessment completed, Interdisciplinary Team review, care plan update, consent after provision of information, order in place, maintenance measured, monitoring resident safety, and physical restraint assessment.
- Continued education provided to all direct care workers, housekeeping, maintenance, social work, therapy, and activities are reminded of bed safety, entrapment zones, bed placement and potential for creating entrapment zones. Mattresses should not move on the bed frame. Mattress stops located on the 4 corners of the bed frame. Staff are responsible for reporting any entrapment zone issues or concerns. All staff who are actively employed by the facility have been trained.
- Education of staff that has not received training (due to illness, vacation, or leave of absence) will be completed before reporting to their workstations on their next schedule day.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
Surveyors found that the facility failed to effectively assess bed rail entrapment risk, document ongoing need, and obtain informed consent for bed rail or grab bar use for four residents with conditions such as heart failure, COPD, Parkinson’s disease, dementia, and severe cognitive impairment. Siderail Data Collection assessments were incomplete, lacking comments, summaries, and any documented entrapment risk evaluation, and no follow-up assessments were completed after the initial entries. In the consolidated Nursing Quarterly/Annual/Significant Evaluation, staff marked that residents had no potential restraints, which automatically disabled the side rail review section and left all bed rail–related questions unanswered. Despite this, observations showed half-length and quarter-length rails or grab bars in the upright position being used for bed mobility and repositioning, while the medical records contained no evidence that risks and benefits were discussed or that informed consent was obtained.
A resident with spastic hemiplegia, muscle weakness, and moderate cognitive impairment was observed using bilateral bed grab bars for bed mobility and transfers, but the care plan did not address grab bar or side rail use. Review of the EMR showed no completed bed mobility device or side rail assessment to determine the necessity or safety of the grab bars, and no documentation that risks and benefits were discussed or that informed consent was obtained. An LPN and the ADON stated that a bed mobility device assessment is required before grab bars are installed and confirmed that no such assessment existed for this resident.
A resident with hypothyroidism and dementia was observed on multiple occasions with bilateral upper side rails in the up position, but the facility failed to follow its bed rail policy. The record lacked an assessment for bed rail use, documentation of alternatives attempted and how they failed, the intended purpose of the rails, a physician order, and a documented risks/benefits discussion with signed consent. The DON confirmed that none of these required steps had been completed, creating potential for injury, entrapment, and/or death.
A resident with vascular dementia, anxiety, delirium, major depressive disorder, and severe cognitive impairment was placed in a bed with rails without a documented bed rail safety assessment or informed consent from the resident or representative. Despite multiple residents having beds with at least one rail, nursing staff reported that no bed rail safety assessments had been completed, and maintenance logs showed only general safety checks without specific bed rail inspections. This occurred even though the facility’s bed safety policy required attempts at alternatives, IDT evaluation, resident assessment, and informed consent before using bed rails.
A resident was found using a quarter-size bed rail on the upper left side of the bed for mobility and repositioning, but record review showed there was no corresponding physician order authorizing bed rail use. During interview, the DON confirmed that no order had been obtained prior to installation, despite requirements to assess safety risks, review risks and benefits, obtain informed consent, and ensure proper installation and maintenance of bed rails.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess Bed Rail Entrapment Risk and Obtain Informed Consent
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective system to assess residents for the risk of entrapment from bed rails, to monitor and document the ongoing need for bed rails, and to obtain and document informed consent after discussing risks and benefits with residents or their representatives. For four sampled residents, the facility used various bed rails or grab bars without documented evidence of entrapment risk assessment or informed consent. The facility’s own Siderail Data Collection assessments were incomplete, with key sections such as comments and summaries left blank, and no documentation that entrapment risk was evaluated. Additionally, subsequent required reassessments were not completed after the initial dates noted in the records. For one resident with diagnoses including heart failure, acute kidney failure, chronic atrial fibrillation, and diabetes, a Siderail Data Collection assessment documented poor bed mobility, use of side rails for positioning, and a desire to have side rails raised, but contained no comments or summary and no evidence of entrapment risk assessment. A later Nursing Quarterly/Annual/Significant Evaluation assessment indicated the resident did not have any potential restraints, which automatically disabled the side rail review questions, leaving them unanswered. There was no documentation that risks and benefits of side rail use were discussed or that informed consent was obtained, even though observations showed half-length bed rails in the upright position on both sides of the bed, which the resident reported using for bed mobility. Another resident with fibromyalgia, rheumatoid arthritis, low back pain, Alzheimer’s disease with late onset, and dementia had a Siderail Data Collection assessment indicating poor bed mobility, use of side rails for support, and balance difficulties, but again with no comments, no summary, and no documented entrapment risk assessment. The Nursing Quarterly/Annual/Significant Evaluation similarly recorded that the resident had no potential restraints, disabling the side rail review section and leaving all related questions unanswered. No evidence was found that risks and benefits of bed rail use were discussed with the resident or representative or that informed consent was obtained, despite observations of a bed grab bar secured to the bedframe and in the upright position. A third resident with heart failure, COPD, and hypertension had a Siderail Data Collection assessment showing poor bed mobility, use of side rails for support, balance difficulties, and a history of falls, with assist rails/quarter rails selected as the device type. However, there were no comments, no summary, and no documentation of entrapment risk assessment, and no further Siderail Data Collection assessments after the initial date. The Nursing Quarterly/Annual/Significant Evaluation again marked that the resident had no potential restraints, disabling the side rail review questions, and there was no evidence of any discussion of risks and benefits or informed consent for bed rail use. Observations showed quarter-length bed rails in the upright position on each side of the bed, which the resident stated were used for repositioning. A fourth resident with Parkinson’s disease, cerebral infarction, and dementia had a Siderail Data Collection assessment documenting poor bed mobility, use of side rails for support, balance difficulties, and a history of falls, with assist rails/quarter rails selected. As with the other residents, the assessment lacked comments and a summary, and there was no evidence of an entrapment risk assessment or any subsequent Siderail Data Collection assessments. The Nursing Quarterly/Annual/Significant Evaluation recorded no potential restraints, disabling the side rail review questions and leaving them unanswered. The record contained no documentation that risks and benefits of bed rail use were discussed with the resident or representative or that informed consent was obtained, even though repeated observations showed quarter-length bed rails in the upright position on both sides of the bed. Interviews with the DON and Administrator confirmed that the consolidated nursing assessment format caused the bed/side rail review questions to be skipped when staff selected that a device was not a restraint, and that informed consent had not been obtained for residents using grab bars, quarter-length, or half-length bed rails.
Failure to Assess, Care Plan, and Obtain Consent for Bed Grab Bar Use
Penalty
Summary
The deficiency involves the facility’s failure to follow required procedures before installing and using bed grab bars for a resident. The resident had diagnoses including spastic hemiplegia affecting the left side and muscle weakness, and an admission MDS indicating moderate cognitive impairment. During observation, the resident was seen in a power chair with bilateral grab bars on the bed and reported using them to roll in bed and for transfers. The resident’s care plan, dated 1/23/26, documented a need for assistance with bed mobility and independence with transfers but did not mention or address the use of grab bars or side rails. Review of the electronic medical record showed no completed grab bar/side rail or bed mobility device assessment to determine the necessity of the grab bars or whether the resident could safely use them. There was also no evidence that the resident or the resident’s representative had been educated on the risks of having a grab bar on the bed or that informed consent had been obtained. In interviews, an LPN and the ADON both stated that a bed mobility device assessment was required to determine need and safety prior to installing grab bars, and both confirmed that no such assessment was present in the resident’s record.
Failure to Assess and Obtain Consent Prior to Bed Rail Use
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy for the safe and effective use of bed rails for one resident. The facility’s policy, reviewed on 9/3/25, required that residents be assessed upon admission, readmission, or upon initiation of bed rail use using the Evaluation for Use of Bed Rails Assessment, that alternatives to bed rails be tried and evaluated, and that the risks and benefits of bed rail use be reviewed with the resident or representative and consent obtained prior to installation. Surveyors observed a resident with multiple diagnoses including hypothyroidism and dementia using bilateral upper side rails in the up position on three consecutive days. On review of the resident’s medical record, surveyors found no documentation of an evaluation of alternatives attempted, no documentation of the purpose or intended use of the side rails, and no documented discussion of risks and benefits with a signed consent for bed rail use. Additionally, there was no physician order for the bed rails. The DON confirmed that the resident had not been assessed for the use of bed rails and that the medical record lacked the required documentation of alternatives, intended purpose, physician order, and consent, despite the facility’s policy requirements. This failure created the potential for harm due to the risk for injury, entrapment, and/or death.
Failure to Assess Bed Rail Safety and Obtain Informed Consent
Penalty
Summary
The deficiency involves the facility’s failure to assess a resident for safety related to bed rail use and to obtain informed consent prior to using bed rails. The resident had diagnoses including vascular dementia, anxiety, delirium, and major depressive disorder, with documentation of severe cognitive impairment, memory problems, and being never or rarely understood per the MDS and CAA. The resident’s care plan noted an alteration in musculoskeletal status related to broken bones in the left wrist/forearm, and the facility documented that his bed was replaced with one without bed rails following an incident. However, the resident’s EHR contained no bed rail risk assessment from admission onward, and there was no evidence that the resident or his representative had been provided information about risks and benefits or had given informed consent for bed rail use. Surveyor interviews and record reviews showed that, prior to the incident involving this resident, the facility had no nursing bed rail safety assessment process in place, despite having 25 residents with at least one bed rail attached to their beds. The Administrative Nurse acknowledged that no nursing bed rail safety assessments had been conducted since her hire and confirmed that no informed consent had been obtained for this resident’s bed rail use. Maintenance staff reported performing general safety checks and provided inspection logs that referenced checking for safety and fall risks but did not specifically address bed rails, and there were no inspection logs specific to bed rails. The facility’s own Bed Safety and Bed Rails policy required attempts to use alternatives, IDT evaluation, resident assessment, and informed consent before bed rail use, but these steps were not carried out or documented for this resident.
Bed Rail Installed Without Required Physician Order
Penalty
Summary
The facility failed to obtain appropriate physician orders prior to installing a bed rail for one resident reviewed for bedrails. The resident was admitted on an unspecified date, and record review of the physician orders showed no order for the use of bedrails. During an observation and interview in the resident’s room, surveyors noted a quarter-size bedrail on the upper left side of the bed, and the resident confirmed he uses the side rail for mobility and to reposition himself. In a subsequent interview, the DON confirmed that the resident did not have physician orders for the use of bedrails and acknowledged that such orders should be in place prior to installation. This deficiency occurred despite regulatory expectations that, before using a bed rail, the facility should assess the resident for safety risk, review risks and benefits with the resident or representative, obtain informed consent, and correctly install and maintain the bed rail.
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