Failure to Monitor and Maintain Bed Rail Safety
Penalty
Summary
The facility failed to ensure that bed rails were properly monitored for safety for a resident who used a half bed rail. During two separate observations, the bed rail on the left side of the resident's bed was found to be loose when moved side to side and back and forth. The resident, who had a diagnosis of Alzheimer's disease and was severely impaired in cognition, confirmed that the bed rail was wiggly. The facility's policy required regular inspection of beds and related equipment by maintenance staff to identify risks, including potential entrapment hazards. Despite this policy, the maintenance supervisor stated that bed rails were not routinely monitored after installation and were only tightened if staff reported them as loose. The maintenance supervisor acknowledged the looseness of the bed rail upon observation and noted that it had been recently installed. The administrator confirmed that CNAs documented issues in the maintenance log if they noticed loose bed rails, but was unaware that maintenance staff were not conducting regular inspections for bed and bed rail safety.