Failure to Conduct Regular Bed and Bedrail Safety Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails as part of a routine maintenance program for a resident with significant cognitive and physical impairments. The resident had diagnoses including dementia, Huntington's disease, and depression, and was dependent on staff for all mobility needs. The care plan indicated the use of bedrails to promote independence, and observations confirmed the presence of half bedrails on both sides of the bed. However, interviews revealed that maintenance staff only checked bedrails for looseness and tightened them monthly, without performing measurements or assessments related to entrapment risks. There was no established schedule for comprehensive inspections of beds, mattresses, or bedrails beyond this limited check. Further, while a physical therapy assistant performed initial bedrail assessments when rails were first installed, there were no ongoing evaluations to monitor changes in the resident's risk of entrapment. The facility's policy required routine inspections to identify risks, including entrapment, and mandated that inspection results be reported to the administrator and QAPI committee. Despite this, maintenance records documenting regular bed inspections and maintenance were requested but not provided, indicating a lack of documentation and follow-through on required safety checks.