Failure to Assess Bed Rail Entrapment Risk in All Required Zones
Penalty
Summary
The facility failed to properly assess the risk of bed rail entrapment for six out of seven residents reviewed for accident hazards. Facility policy required maintenance staff to conduct bed inspections for entrapment points using a measurement device, following the manufacturer's test methods, but the policy did not specify all entrapment zones. Specifically, staff consistently assessed only zones 1-4 and omitted assessment of zone 6, which is the space between the end of the rail and the side edge of the headboard or footboard, as outlined in FDA guidance. This omission was confirmed through staff interviews and review of facility documentation. Multiple residents were observed with enabler or assist bars attached to their beds, and clinical records showed active physician orders for these devices. For each resident reviewed, documentation indicated that only zones 1-4 were assessed for entrapment risk, with no evidence that zone 6 was evaluated. Residents reported using the bars to assist with mobility and transfers, and their beds were equipped with headboards and footboards, making the unassessed zone 6 relevant for potential entrapment risk. The lack of assessment for this zone was consistent across all reviewed cases. During interviews, facility leadership and maintenance staff acknowledged that zone 6 was not included in their standard assessment process. Additionally, the facility was unable to provide the manufacturer's identification information for the beds and assist bars when requested by surveyors. The deficiency was cited under 28 Pa. Code 211.12 (d)(5) for nursing services.