Failure to Assess Bed Rail Entrapment Risk After Mattress Replacement
Penalty
Summary
Facility staff failed to properly assess and ensure the safe use of bed rails for a resident who required assistance with bed mobility. The resident, who had diagnoses including wheezing, pneumonia, sleep apnea, and weakness, was assessed to use double half side rails for mobility and was able to use the rails to assist with turning and repositioning. However, the resident also required partial to moderate assistance to roll and extensive assistance from staff for bed mobility, as documented in the care plan. On the night of the incident, staff replaced the resident's mattress with an alternating pressure air mattress due to the previous mattress not holding air. The new mattress was installed on a bed with side rails attached, but staff did not assess the entrapment zones between the mattress and the side rails after the replacement. This omission was contrary to facility policy, which required assessment of bed rail and mattress compatibility to prevent gaps that could entrap a resident. The facility's policy also specifically prohibited the use of side rails with air mattresses due to entrapment risk. As a result of the failure to assess the entrapment zones, the resident was found with his head trapped between the mattress and the side rail, unable to free himself and experiencing pain and skin tears. Staff had difficulty removing the resident's head from the gap, and the incident was later confirmed by a bed rail gap test, which the bed did not pass. The entrapment assessment had not been performed when the mattress was swapped, leading directly to the resident's injury.
Removal Plan
- Updated policy to include side rails will not be used with air mattresses
- Licensed nurses were educated on the side rail policy, Side Rail Assessment, Bed Rail/Mattress Safety Assessment including how to measure for gaps that may cause entrapment