Failure to Maintain Secure Bed Rail Attachment
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment was found to have a bed rail that was not securely fastened to the bed frame. The bed rail, located on the upper right side of the bed and covered with padding, was observed to be loose, with approximately six to seven inches of movement back and forth and leaning away from the mattress by the same distance. The bracket attaching the bed rail to the bed frame was also observed to be loose during multiple observations on consecutive days. Staff interviews revealed that there was no routine schedule for checking bed rails for safety, and maintenance was only notified when staff identified an issue. The Resident Care Manager and LPN were unsure if the bed rail should be tighter, and the DON confirmed that the bed rail was too loose. The Maintenance Director also confirmed the need for tightening after inspecting the bed rail. These observations and interviews demonstrated a failure to ensure that bed rails were securely fastened and free of gaps, as required.