Failure to Identify and Address Bed Entrapment Hazards
Penalty
Summary
The facility failed to conduct effective inspections of bed frames, mattresses, and bed rails to identify and address risks of entrapment for residents. Maintenance staff did not ensure that mattresses were compatible with bed frames, resulting in exposed gaps and mechanical parts that could entrap body parts. The facility's bed safety policy required inspections using a specific measurement device, but staff were not trained on its use or aware of the required safety measurements. Recent bed inspections only evaluated electrical mechanics and did not assess mattress and bed frame compatibility or potential entrapment hazards. Surveyors observed multiple instances where residents were at risk due to improper bed equipment. One resident with hemiplegia and osteoporosis was found in a bed with exposed frame holes and a bed rail positioned in a way that created entrapment risks. Another resident had a mattress that was too small for the frame, exposing sharp metal edges and mechanical parts, and was observed with a skin tear. A third resident's mattress was too short, leaving a significant gap at the foot of the bed. Interviews with staff confirmed a lack of knowledge and training regarding proper bed safety inspections.