Failure to Assess Entrapment Risk Prior to Bedrail Use
Penalty
Summary
The facility failed to assess the risk of entrapment prior to the use of bilateral bedrails for a resident who was admitted with diagnoses including unspecified psychosis, dementia with behavioral disturbance, and a need for assistance with personal care. During an observation, the resident's bed was found with small bilateral bedrails in the raised position. Record review and interviews with the registered nursing supervisor and the director of nursing confirmed that there was no completed assessment for risk of entrapment in the resident's health record. Further interviews revealed that the resident had the bedrails in place since admission, and only staff could operate the rails due to a locking mechanism. Review of the facility's policy indicated that an assessment for risk of entrapment should be completed when side rails are used for mobility or transfer. The lack of this assessment constituted a failure to follow facility policy and ensure resident safety regarding bedrail use.