Deficiency in Bed Entrapment Assessments and Inspections
Summary
The facility failed to ensure that entrapment assessments were completed and measurements were recorded during bed inspections for residents using side rails. This deficiency was observed in four residents who were reviewed for side rail use. The facility also did not conduct regular inspections of all beds, which could potentially lead to resident entrapment, serious injury, or death. The facility's policies and procedures required regular inspections and assessments to prevent such risks, but these were not adequately followed. For Resident 13, there was no documented evidence of an entrapment assessment prior to the installation of side rails, despite the resident's use of the rails for mobility assistance. The maintenance department was responsible for installing the side rails and measuring gaps, but the necessary assessments were not completed. Similarly, Resident 29's records showed that while the resident requested grab bars and understood the risks, the entrapment assessment was incomplete, with certain zones not evaluated. The maintenance staff was responsible for these evaluations, but the documentation was inconsistent and incomplete. Resident 37's records indicated that while the resident was cognitively intact and used grab bars for mobility, the entrapment assessment was not fully conducted, with some zones marked as not applicable without proper justification. Additionally, Resident 5's records showed that the entrapment assessment did not include Zone 2, which was necessary for a complete evaluation. The Environmental Services Director confirmed these findings, acknowledging that the assessments were not conducted with the resident in bed and that documentation was lacking for beds without grab bars.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with multiple medical conditions was found to have a low air loss mattress that overhung the bed frame by about five inches, preventing the installation of a grab bar on one side. The Maintenance Director confirmed the mattress was too large for the frame and not fully supported.
A resident with cognitive impairment and multiple health conditions was found to have a mattress that did not fit the bed, creating a large gap. The facility lacked a program for regular inspections of bed frames, mattresses, and bedrails. The Maintenance Supervisor noted a nine-inch gap, and the DON confirmed the bed was a rental, acknowledging the need for an extender or longer mattress.
A resident with quadriplegia was found to have unsafe gaps between their mattress and bed rails, with measurements of 5.25 inches on the left and 3.25 inches on the right. The DON confirmed these gaps were too large and potentially unsafe, and the facility could not provide manufacturer guidelines for acceptable distances.
The facility failed to assess the use of side rails/enabler bars for two residents with cognitive impairments and multiple diagnoses. Interviews revealed that enabler bars were not assessed for proper fit or need upon admission or routinely thereafter, despite the facility's policy requiring such assessments.
A facility failed to ensure a resident's mattress fit properly on the bed frame, resulting in a 12-inch gap between the headboard and the mattress. The resident, who had multiple diagnoses and was dependent on staff for all ADLs, was at risk due to this safety issue. The facility's policy on mattress inspection and bed safety was not followed.
Incompatible Mattress and Bed Frame Resulting in Unsafe Bed Setup
Penalty
Summary
The facility failed to ensure that a mattress and bed frame were compatible for a resident with morbid obesity, muscle weakness, and Type II Diabetes Mellitus. The resident, who was cognitively intact and required a low air loss mattress at all times, reported that the mattress was too large for the bed frame. Observation confirmed that the mattress overhung the bed frame by approximately five inches, and a grab bar could not be installed on one side of the bed due to the mattress's size. The Maintenance Director acknowledged that the mattress was not fully supported by the frame and confirmed awareness of the issue.
Incompatible Mattress and Bed Frame
Penalty
Summary
The facility failed to ensure that a mattress was compatible with a bed, affecting a resident with anoxic brain damage, tracheostomy status, and generalized idiopathic epilepsy. The resident, who had moderate cognitive impairment and was dependent on staff for all activities of daily living, was observed to have a mattress that did not fit the bed, leaving a large gap between the end of the bed footboard and the mattress. The Maintenance Supervisor was unsure if the bed was a rental or a bariatric bed from the facility and noted a nine-inch gap between the mattress and the end of the bed. The facility lacked a program for regular inspections of bed frames, mattresses, and bedrails. The Director of Nursing confirmed the bed was a rental and acknowledged the need for an extender or longer mattress, verifying that there should not be a space between the mattress and the bed. The manufacturer's guidelines indicated that the mattress should be sufficiently wide and long enough to prevent any part of the patient's body from falling between the bed and mattress.
Unsafe Bed Rail and Mattress Configuration
Penalty
Summary
The facility failed to ensure the safety of bed rails and mattresses for a resident with quadriplegia and acute and chronic respiratory failure. The resident, who was dependent on staff for all Activities of Daily Living (ADLs) and rarely/never understood, was observed lying on an air mattress with significant gaps between the mattress and bed rails. These gaps were measured at 5.25 inches on the left side and 3.25 inches on the right side, which were confirmed by the Director of Nursing (DON) to be potentially unsafe. The deficiency was identified during an observation and confirmed through interviews with staff, including a Licensed Practical Nurse (LPN) and the DON. The facility was unable to provide manufacturer guidelines for the acceptable distance between the mattress and bed rails, but the DON acknowledged that the existing gaps were too large and posed a safety risk. This issue affected one of the two residents reviewed for bed rails, highlighting a lapse in ensuring the safety and appropriateness of bed rail and mattress configurations.
Failure to Assess Side Rails/Enabler Bars
Penalty
Summary
The facility failed to assess the use of side rails/enabler bars for two residents, leading to a deficiency. Resident #33, who had severe cognitive impairment and required extensive assistance for activities of daily living, was admitted with multiple diagnoses including dementia with behavioral disturbance. The care plan for Resident #33 included a mobility bar to assist with mobility, but no assessments for side rails or enabler bars were completed. Similarly, Resident #58, who had moderate cognitive impairment and was dependent on staff for activities of daily living, had a care plan that included a mobility bar, but no assessments were conducted for side rails or enabler bars. Interviews with the Maintenance Director and Assistant Director of Nursing revealed that enabler bars were not assessed for proper fit or need upon admission or routinely thereafter. The Director of Nursing confirmed that no assessments had been completed for any residents with enabler bars or side rails, despite the facility's policy requiring such assessments at least quarterly or upon significant changes in status. The lack of assessments for side rails and enabler bars was acknowledged as an issue that needed to be addressed throughout the facility.
Improper Mattress Fit on Bed Frame
Penalty
Summary
The facility failed to ensure a resident's mattress fit properly on the bed frame, affecting one resident out of the 134 residents in the facility. The resident, who had multiple diagnoses including dementia, epilepsy, and congestive heart failure, was dependent on staff for all activities of daily living and had impaired cognition. A bed safety evaluation revealed the resident had poor bed mobility and difficulty sitting on the side of the bed, and was unable to transfer independently or use a call light for help. An observation of the resident's bed showed a gap of approximately 12 inches between the headboard and the mattress, which was confirmed by a staff member as a safety risk. The facility's policy on the use of support surfaces indicated that mattresses should be inspected regularly to identify areas of possible entrapment and ensure they fit the bed frame properly. However, the policy was not followed in this case, as evidenced by the large gap observed. The Regional Clinical Nurse confirmed that such a gap could pose a safety risk and potentially harm the resident. The facility's failure to adhere to its own policy on mattress inspection and bed safety led to this deficiency.
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