Failure to Prevent Accident Hazards and Ensure Safe Bed Rail Installation
Penalty
Summary
The facility failed to ensure that a resident at high risk for falls received adequate supervision and individualized fall interventions, and also failed to ensure that bed rails were installed in a manner that would prevent entrapment. The resident, an elderly female with multiple diagnoses including dementia with agitation, atrial fibrillation, diabetes, and hypertension, was assessed as a high fall risk with poor safety awareness and cognitive deficits. Despite her care plan indicating the need for partial to moderate assistance with transfers and toileting, staff reported inconsistent understanding of her needs, with some stating she could transfer independently and others noting she required extensive assistance and supervision. On the day of the incident, the resident was found kneeling on the floor next to her bed, with her right arm trapped between the side rail and the mattress, and her wheelchair positioned behind her. She was unable to explain what had happened and was experiencing significant pain in her right arm. The call light in the room had been activated by her roommate, not the resident herself, as she did not typically use the call light for assistance. Staff interviews revealed that the resident was forgetful, did not remember to use the call light, and would attempt to get up without assistance if left unsupervised. Observations confirmed that there was a gap between the mattress and the side rail wide enough for entrapment, and the bed rails were in the upright position at the time of the incident. Review of facility policies showed that bed rails should only be used after appropriate alternatives have been attempted, with informed consent and a physician's order required. The policy also mandates that installation must prevent gaps that could lead to entrapment. The resident's care plan interventions were not individualized, with repeated instructions to use the call light despite her cognitive deficits and history of non-compliance. The facility's failure to provide adequate supervision, individualized interventions, and safe installation of bed rails resulted in the resident sustaining a comminuted fracture of the right humerus.