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:
Bed rail use without informed consent and without attempted alternatives. The DON could not provide documentation of informed consent before installing bed rails for two residents, including one resident with severe cognitive impairment, dementia, stroke with hemiplegia, and dependence for bed mobility and transfers. For another resident with moderate cognitive impairment, dementia, heart failure, and respiratory failure, the DON also could not provide documentation of alternative interventions attempted before four half rails were installed. Care plans and restraint/device assessments documented rail use, but one assessment had blank safety fields and the DON stated consent was not obtained because the rails were not considered a restraint.
Bed rails used without order, consent, or documented need. A resident with osteoarthritis, a recent knee replacement, and moderately impaired cognition was observed with bilateral siderails up even though the BRA said bed rails were not needed, the resident said they were not needed, and the EMR had no physician order or consent for their use. Staff and the facility P&P stated informed consent and a physician order were required before installation.
Failure to assess and document bed rail use for a resident with schizophrenia and depression. The resident was observed with one upper bed rail in the up position, but the chart lacked documentation of a resident assessment, alternatives tried, the purpose for the bed rail, a physician order, and a discussion of risks and benefits with signed consent. The DON stated the resident had not been assessed for bed rail use and should not have had the rail in use.
Failure to assess side rail entrapment risk and obtain informed consent. A resident with stroke-related weakness and no cognitive impairment used a side rail to get in and out of bed, but the EHR contained no consent for the rail and no entrapment zone measurements. Therapy notes described the bed assist rail as safe and helpful, while a later Bed Safety Evaluation only addressed a limited gap check and staff could not locate any entrapment checks or consent.
A resident with bilateral 1/4 side rails in use did not have a required Bed Rail Assessment completed. The resident had diagnoses including metabolic encephalopathy, abnormal posture, muscle weakness, and bilateral hip OA, and the care plan identified side rails as an enabler for transferring, repositioning, and ADL care. Staff stated the assessment should be completed before bedrails are implemented and then annually, but it had not been done for this resident.
Failure to obtain order and informed consent for bed rails: A resident with DM, depression, PVD, intact cognition, and bilateral AKA was observed in bed with half side rails on both sides. The LVN and DON stated there was no physician order or informed consent from the resident or representative before the rails were installed, despite the facility P&P requiring staff to explain benefits and hazards and obtain informed consent before using bed rails.
Bed rail use without informed consent and without attempted alternatives
Penalty
Summary
The facility failed to obtain informed consent before installing bed rails for 2 residents and failed to attempt bed rail alternatives before installation for 1 resident. Resident #4 had severe cognitive impairment with a BIMS score of 3, diagnoses including non-Alzheimer's dementia, stroke with right-sided hemiplegia, malnutrition, and anxiety disorder, and required substantial to maximal assistance with bed mobility and dependent assistance with transfers. The MDS identified daily use of a bed rail as a physical restraint, and the care plan described full bed side rail use for safety and independence with bed mobility, with instructions to discuss risks and benefits with the resident/family/caregivers and obtain a provider order when used as a restraint. The restraint/device/enabler assessment for Resident #4 identified one full side rail and one half side rail that prevented independent entry and exit from the bed when in use. The assessment indicated no other alternative measures were attempted or used, and listed risks and benefits of the device. During observation, the resident was in bed with the right side of the bed placed against the wall, a half rail upright on the right, and a full rail upright on the left with padding fixed to the inside of the rail. The DON stated the resident had used a low bed and fall mat before the full bed rail was implemented, but could not provide documentation of informed consent for bed rail use prior to installation. Resident #25 had moderate cognitive impairment with a BIMS score of 8, diagnoses including non-Alzheimer's dementia, heart failure, respiratory failure, and adjustment disorder with mixed anxiety and depressed mood, and was dependent on staff assistance for bed mobility and transfers. The care plan described top and lower half rails as an enabling device to promote independence, and another care plan addressed fall risk with interventions including a rail attempted with a pool noodle, a padded overlay, a low bed, and mattress/rail spacing checks. However, the restraint/device/enabler assessment for four half bed rails had blank responses for safety risk and additional safety measures, and the DON stated informed consent had not been obtained because the rails were not used as a restraint and could not provide documentation of alternative interventions attempted before installation.
Bed rails used without order, consent, or documented need
Penalty
Summary
The facility failed to implement its Policy and Procedure on the use of bed rails/siderails for Resident 64. Resident 64 was admitted with diagnoses including osteoarthritis and right knee joint replacement surgery. The Bed Rails Assessment dated 4/11/2026 indicated the resident did not need bed rails, and the Minimum Data Set dated 4/15/2026 showed moderately impaired cognition, supervision or touching assistance with oral hygiene, upper body dressing, and personal hygiene, partial/moderate assistance with toileting and lower body dressing, and dependence with showering. On 5/19/2026, surveyors observed Resident 64 sitting on the edge of the bed with bed rails/siderails up on both sides of the bed. CNA 2 stated the resident was able to sit, stand, and walk with supervision, and the resident stated the siderails were not needed and had not been requested. Record review showed no active order for bilateral 1/2 bed rails and no consent for their use in the EMR. Staff interviews confirmed that residents with bed siderails should have a physician's order and consent before installation, and the facility's P&P required informed consent after alternatives had been attempted and then a physician's order for the specified bed rail.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to ensure that, before a bed rail was placed in use, Resident #3 had a documented assessment that included alternatives attempted and how those alternatives failed to meet the resident’s assessed needs. The facility’s Proper Use of Bed Rails policy, reviewed on 6/5/25, required the resident assessment to evaluate alternatives tried before installation or use of a bed rail, assess the resident’s risk from using bed rails, obtain informed consent after alternatives were attempted, and then obtain a physician’s order for the specified bed rail and the medical reason for its use. Resident #3 was initially admitted and later readmitted to the facility with diagnoses including schizophrenia and depression. On 5/11/26 and 5/12/26, the resident was observed with one upper bed rail on the bed in the up position. On 5/12/26 at 10:05 AM, the medical record did not document a resident assessment, evaluation of alternatives attempted, the purpose for the bed rail, a physician order for the bed rail, or a documented discussion of risks and benefits with signed consent. At 1:42 PM, the DON stated the resident had not been assessed for the use of bed rails and should not have had the bed rail in use, but did.
Failure to assess side rail entrapment risk and obtain informed consent
Penalty
Summary
The facility failed to appropriately assess a side rail for entrapment zone risks and failed to obtain informed consent for side rail use for one resident reviewed for accident hazards. The resident had diagnoses including muscle weakness, hemiplegia, and hemiparesis following a cerebral infarction affecting the left non-dominant side. A quarterly MDS dated February 10, 2026, showed a BIMS score of 15, indicating no cognitive impairment. During observation and interview on May 6, 2026, the resident had a side rail attached to the right side of the bed, positioned in the down position but still several inches above the mattress, and stated that she used the side rail to get in and out of bed. When documentation was requested, the facility reported the records should be in the EHR, but no documentation was found for consent to use the side rail or for entrapment zone measurements. Therapy documentation from May and June 2025 noted the resident had received a bed assist rail and had been assessed as able to place and remove it safely, with improved bed mobility and good safety and management of the railing. However, a Bed Safety Evaluation dated March 19, 2026, only addressed whether there was a gap between the head or foot board and mattress and indicated that all questions had been answered yes, with rails/devices not required, and no further entrapment zone assessment was documented. Staff interviews confirmed therapy handled bed rail safety assessments but not entrapment zone assessments, and maintenance staff could find no entrapment zone checks or informed consent related to the resident's side rail.
Missing Bed Rail Assessment for Resident with Side Rails
Penalty
Summary
The facility failed to ensure that a Bed Rail Assessment was completed for one of eight sampled residents who had bed rails in use. Resident 1 was admitted with diagnoses including metabolic encephalopathy, abnormal posture, muscle weakness, and bilateral osteoarthritis of the hip. The resident’s MDS dated 6/29/2025 indicated the resident was cognitively intact. The care plan dated 1/21/2026 stated that bilateral 1/4 side rails were to be used while the resident was in bed as an enabler for transferring, repositioning, and during ADL care. Review of the resident’s Standard Assessments showed the Bed Rail Assessment was past due as of 2/6/2026. During observation on 5/7/2026, the resident was lying in bed with the head of the bed elevated and bilateral 1/4 side rails up. During interview, the RN stated Bed Rail Assessments are to be completed by the MDSC, LVN, or RN prior to implementing bedrails, and the MDSC stated that Bed Rail Assessments are completed upon admission and annually for residents who use bed rails and that one had not been completed for Resident 1. The facility policy titled Proper Use of Bed Rails stated the resident assessment should assess risks of entrapment between the mattress and bed rail or in the bed rail itself and determine whether the bed rail meets the definition of a restraint.
Failure to Obtain Order and Informed Consent for Bed Rails
Penalty
Summary
The facility failed to implement its Policy and Procedure on the use of bed rails for one sampled resident. Resident 106 was admitted with diagnoses including DM, depression, and PVD. The MDS dated 5/8/2026 indicated the resident had intact cognition and required varying levels of assistance with activities of daily living, including partial/moderate assistance with oral hygiene and upper body dressing, substantial/maximal assistance with toileting, showering, and lower body dressing, and dependence with personal hygiene. During an observation on 5/5/2026, Resident 106 was in bed with one-half bedrails up on both sides of the bed. Resident 106 stated that help was needed with bed mobility and had bilateral above-the-knee amputations. During a concurrent interview and record review, LVN 2 stated there was no physician order and no informed consent from the resident or representative before the bilateral half side rails were installed. The DON also stated that a physician order and informed consent should have been obtained before installation of siderails. The facility's undated Bed Safety and Bed Rails P&P stated that before using bed rails, staff shall inform the resident or representative about the benefits and potential hazards and obtain informed consent, including the assessed medical needs addressed and the resident's risks from bed rail use.
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