Failure to Conduct Timely Bed Safety and Entrapment Assessments
Penalty
Summary
The facility failed to ensure that bed safety inspections and entrapment assessments were properly conducted for residents using bed rails, as required by facility policy and federal guidance. Specifically, for two residents, there were documented gaps between the mattress and the side/bed rail, headboard, and footboard, which were identified during initial nursing evaluations. Despite these findings, there was no evidence that maintenance staff performed follow-up inspections or entrapment assessments in response to these identified risks. For one resident, the initial evaluation noted gaps that could pose entrapment risks, but the Director of Maintenance confirmed that he did not conduct a new inspection or assessment after the resident's admission or after changes in the bed or mattress. The maintenance department relied on annual inspections and only performed additional checks if a low air loss mattress was used or if repairs were requested by nursing staff. Documentation provided by the Director of Maintenance showed that some entrapment zones were not assessed, and certain required measurements were left blank. For another resident, the initial evaluation also indicated gaps between the mattress and bed components, but the Director of Maintenance was unaware of these findings and could not provide documentation of a bed entrapment assessment for this resident. The facility's process did not ensure that entrapment risks identified by nursing staff were communicated to or addressed by maintenance, resulting in a lack of timely and comprehensive bed safety assessments for residents at risk.