Failure to Assess and Maintain Bed Rail and Mattress Safety
Penalty
Summary
The facility failed to ensure proper assessment and maintenance of bed rails and mattresses for one resident reviewed for accident hazards. The resident in question had a history of traumatic brain injury, cognitive communication deficit, difficulty walking, and general weakness. Upon observation, the resident was found sitting at the edge of his bed with the mattress shifted, exposing six inches of the metal bed frame. The mattress, which was a specialty air mattress, was easily compressed and slid with minimal effort, creating a gap of five inches between the mattress and the bed rail while the resident was in a sitting position. The resident had visible bruises and a dressing on his leg, and he was unable to recall the cause of his injuries due to short-term memory loss. No staff were present in the room during the observation. Interviews with facility staff revealed that the maintenance director kept bed safety assessment forms in his office, but the form for this resident allowed for a maximum gap of 2 3/8 inches, while the observed gap exceeded this measurement. The mattress was also found to be easily compressed, further increasing the gap beyond regulatory limits. The assessment for bed system entrapment zones was only completed on one day and did not specify whether the resident was in bed at the time of measurement. Additionally, the assessment did not include the required documentation of the maximum acceptable gap for the resident, as mandated by state guidelines. Review of the resident's medical record showed only one restraint/enabler assessment, which was completed after the surveyor identified the bed safety concerns. This assessment noted the use of bilateral assist rails but did not address measurements or entrapment risks. No other relevant assessments, measurements, or physician orders were found in the record to evaluate the resident's risk of bed rail entrapment, indicating a lack of ongoing monitoring and documentation as required by state regulations.