Inaccurate Bed Entrapment Assessments for Residents Using Side Rails
Penalty
Summary
The facility failed to ensure that entrapment assessments for bed systems were accurate and complete for several residents who used side rails. Specifically, for four residents reviewed, there were discrepancies and inaccuracies in the measurements and zone assessments for bed entrapment risks. The facility's own policies required regular inspection and assessment of bed frames, mattresses, and side rails, including the evaluation of specific entrapment zones as outlined by FDA guidance. However, the assessments documented in the residents' records did not match the actual measurements and findings when re-assessed by staff using the appropriate measurement device. For one resident, the initial entrapment assessment indicated that several zones failed, but a subsequent assessment revealed different measurements and additional failed zones, indicating the original documentation was inaccurate. Another resident's assessment form was incomplete, with critical sections left unmarked, and the zone assessments did not match the findings from a later, more accurate measurement. In both cases, the staff acknowledged that the original assessments were not accurate compared to the re-assessments conducted during the survey. Similar discrepancies were found for two other residents, where the bed inspection measurements and entrapment assessments on file did not align with the actual measurements taken during the survey. In some cases, the beds were measured using a similar bed rather than the actual bed in use, and the results showed differences in mattress length and zone pass/fail status. These failures to accurately assess and document bed system safety had the potential to negatively impact residents by increasing the risk of entrapment.