Failure to Assess and Document Bed Rail Safety
Penalty
Summary
The facility failed to assess bed rails for safe use for five sampled residents who had bed rails on their beds. Observations revealed that each of these residents had bed rails or grab bars on both sides of their beds, but there was no documentation that an assessment had been completed to determine the safe use of the bed rails or to measure the risk of entrapment and injury. The residents' electronic medical records indicated that device evaluations for bed rail use had been completed at various times, but none included the required safety assessments or measurements. Interviews with staff revealed further gaps in the facility's practices. The physical therapist reported that she had assessed bed rails for all residents using them in early 2023 but had not conducted any regular maintenance inspections since then. The physical plant manager stated he had not completed measurement assessments for the safe use of bed rails for any residents and was unaware that such assessments had not been performed since 2023. The DON was also unaware of the need for regular maintenance inspections or measurements to determine the safe use of bed rails. A review of the facility's undated Bed Safety policy indicated that monthly inspections of all bed frames, mattresses, and bed rails were required as part of a regular preventative maintenance program. The policy also required that gaps within the bed system be reviewed to ensure they were within FDA-established dimensions and that bedrails be properly installed according to manufacturer instructions. Despite these policy requirements, the facility did not have documentation or evidence that these inspections and assessments were being performed as required.