Failure to Conduct Bed Rail Risk Assessments and Measurements for New Admissions
Penalty
Summary
The facility failed to ensure that maintenance staff conducted proper bed rail risk assessments, including evaluation of the bed and measurements of siderails and potential bed entrapment zones, for two newly admitted residents. For one resident with muscle wasting, atrophy, morbid obesity, and moderate cognitive impairment, documentation of a bed rail evaluation with corresponding measurements was not provided. Although maintenance staff stated that bed rails were checked monthly and during admission, the inspection forms only indicated that rooms were assessed without recording the actual measurements required to identify entrapment risks. The facility's policy requires compatibility checks and measurements prior to use, but these were not documented. For another resident with osteoarthritis, generalized muscle weakness, and moderate cognitive impairment, no bed entrapment assessment was performed at admission because the measuring equipment was broken. The resident's siderail evaluation for risk of bed entrapment was not completed as required. The facility's policy specifies that bed frames, mattresses, and bed rails must be checked for compatibility and size, and that maintenance staff must routinely inspect all beds and related equipment for potential entrapment risks, but these procedures were not followed for the two residents.