Failure to Conduct Regular Bed Rail Safety Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed rails as part of its maintenance program, as required by its own policy. The Environmental Services Director (ESD) reported that bed rails were only checked when a work order was received for installation or on an as-needed basis, rather than as part of a routine inspection schedule. This lack of regular inspection was confirmed during interviews and observations conducted by surveyors. Four residents were identified as having bilateral enabler bars or quarter side rails on their beds, but there was no evidence that these bed rails had been regularly inspected for safety or potential entrapment risks. For example, one resident had physician orders and care plans indicating the use of assist rails for skin integrity and bed mobility, while another had a side rail evaluation and verbal consent for repositioning bars, but no ongoing re-evaluation or documented inspections. Observations during the survey confirmed the presence of these devices on the residents' beds. The facility's policy requires regular inspection and maintenance of bed rails and mattresses to ensure safety and prevent entrapment, with responsibility assigned to the maintenance director or designee. Despite this, interviews with facility leadership and staff revealed that these inspections were not being performed as required, and no additional information or documentation was provided to demonstrate compliance with the policy.