Failure to Assess and Implement Safety Measures After Bed Rail Removal
Penalty
Summary
The facility failed to maintain a safe environment and provide adequate supervision and equipment to prevent accidents for one of four sampled residents. Staff removed the resident's bed rails without conducting a safety assessment, despite documentation indicating a history of falls from bed and a care plan that included the use of partial bed rails at all times. No assessment was completed to determine if the resident would be safe without the bed rails, and no alternative safety interventions were implemented at the time of removal. The resident, who had diagnoses including chronic obstructive pulmonary disease, muscle wasting and atrophy, repeated falls, and required assistance with personal care, was moderately cognitively impaired. During care, the resident rolled out of bed after the bed rails had been removed, sustaining a head laceration that required emergency room treatment, including x-rays and stitches. Staff interviews confirmed that the resident previously used the bed rails for assistance with turning and that their removal was based on a facility-wide policy change, not on an individualized assessment. Observations and interviews revealed that the resident was being assisted by a CNA at the time of the fall, who turned the resident and then reached for supplies, during which the resident rolled off the bed. The incident resulted in a significant injury, and it was confirmed by the DON and other staff that no side rail assessment was completed at the time of removal and no other safety measures were put in place to prevent injury after the bed rails were taken off.