Failure to Assess Bed Rail Safety with Low Air-Loss Mattresses
Penalty
Summary
The facility failed to ensure that two residents who used bed rails in conjunction with low air-loss mattresses received appropriate safety assessments that acknowledged the specific risks associated with this combination. For one resident with diagnoses including general anxiety disorder, obesity, schizoaffective disorder, and post-traumatic stress disorder, documentation showed she was dependent on staff for all activities of daily living and used a low air-loss mattress with bilateral assist rails. However, her care plan and electronic medical record lacked any assessment or documentation addressing the risks of using bed rails with her low air-loss mattress, despite facility policy requiring such evaluation. Another resident with multiple diagnoses, including multiple sclerosis, diabetes, edema, COPD, muscle weakness, dementia, and obesity, also used half-bed rails on both sides of the bed to assist with repositioning. The care plan indicated the use of bed rails, but the side rail assessment did not include consideration of the low air-loss mattress. There was no evidence in the medical record that the risks and benefits of bed rail use with the low air-loss mattress were reviewed with the resident or representative, nor that education was provided regarding these risks. Interviews with staff revealed uncertainty about whether bed rail assessments covered the risks associated with low air-loss mattresses and who was responsible for ensuring the safety of the bed system after mattress changes. Observations confirmed that both residents were using bed rails with low air-loss mattresses, and staff acknowledged that safety checks and measurements specific to this setup were not consistently performed. The facility's own policy required interdisciplinary assessment of the sleeping environment, including bed system risks, but this was not followed in these cases.