Failure to Ensure Safe Bed Rail Dimensions and Monitoring
Penalty
Summary
The facility failed to ensure that a resident's bed dimensions were appropriate, resulting in a 10-inch gap between the mattress and the bed rail. This gap was observed when the resident, who has hemiplegia and hemiparesis affecting the left side and osteoporosis, was found lying in bed with the mattress smaller than the bed frame and offset, creating a wedge-shaped gap. The resident's care plan indicated limited mobility, risk for falls, and use of bed rails for independent mobility, with dependence on two staff for turning and repositioning. The FDA recommends a maximum gap of less than 4 3/4 inches between the bed rail and the compressed mattress, but the observed gap was significantly larger. Additionally, the facility failed to regularly inspect and monitor bed rails for all residents using them, affecting 35 out of 35 residents with bed rails. During an interview, the Maintenance/Housekeeping/Laundry Supervisor acknowledged having a tool to measure bed rail gaps but did not know how to use it or the correct measurements. The surveyor confirmed that the mattresses did not fit the bed frames, creating the potential for entrapment of body parts.