Failure to Comprehensively Assess Bed Rail Use and Entrapment Risk
Penalty
Summary
The facility failed to conduct a comprehensive assessment prior to the use of bed rails for a resident with moderate to severe cognitive impairment, Huntington's disease, and depression, who was dependent for all mobility needs. The resident's care plan indicated the use of bed rails to promote independence, but the Bedrail Risk Assessment (BRA) did not address all required safety zones as outlined by FDA guidance, specifically lacking information for zones 1, 2, the footboard portion of zone 6, and zone 7. Additionally, the BRA did not document what alternatives to bed rails were attempted before their use. Observations confirmed that half bedrails were installed on both sides of the resident's bed. Interviews with facility staff revealed that maintenance installed bedrails after confirming provider orders but did not perform measurements or assessments related to entrapment risks. The physical therapy assistant, responsible for bedrail assessments, acknowledged that only limited measurements were taken and that the most recent assessment did not fully address all entrapment zones. Facility policy required compatibility checks and adherence to FDA safety dimensions, but these were not fully documented or implemented in this case.