Failure to Ensure Proper Bed Rail Installation, Assessment, and Maintenance
Summary
The facility failed to ensure the correct installation, use, and maintenance of bed rails for three residents reviewed for bed rail use. Specifically, the facility did not have the manufacturers' recommendations and specifications available or follow them for installing and maintaining bed rails, resulting in a large gap in one resident's bed rail. Observations revealed that a bed rail was loose and had a gap of approximately 14 to 18 inches between the mattress and the rail, and staff reported that the issue had persisted for 2-3 months without being properly reported or addressed. The Director of Plant Operations was unaware of the issue until surveyor intervention and did not maintain documentation or a log of maintenance requests or repairs, nor did he have the manufacturer manuals for the beds or bed rails. Additionally, the facility failed to develop care plans that addressed the risk of entrapment and did not implement interventions to prevent entrapment for residents with a history of falling out of bed. Care plans for these residents did not include the risk of entrapment, and bed mobility assessments indicated that bed rails were not recommended for use, yet the rails remained in place. Multiple incident reports documented repeated falls from bed for these residents, and consent forms for bed rail use were present but not aligned with current assessments or care plans. The facility also did not provide maintenance and monitoring of bed rails according to manufacturer specifications or recommendations. There was no evidence of regular, documented inspections, and staff were not consistently trained on the proper procedures for reporting broken or malfunctioning bed rails. The lack of proper installation, assessment, and maintenance of bed rails placed residents at risk for entrapment, serious injury, or death, as directly stated in the report.
Removal Plan
- The Director of Plant Operations changed the bed for resident #70 with properly operating bed rails.
- The Charge Nurse reassessed resident #70 for bed mobility and the bed mobility assessment for resident #70 was updated. The use of side rails was recommended per assessment.
- The Charge Nurse reassessed resident #102 for bed mobility and the bed mobility assessment for resident #102 was updated. The use of side rails was not recommended per assessment.
- The Director of Plant Operations removed the assist bar for resident #102 per recommendations from assessment.
- The Charge Nurse reassessed resident #87 for bed mobility and the bed mobility assessment for resident #87 was updated. The use of one bed rail for turning and repositioning recommended per assessment.
- The Director of Plant Operation removed the right bed rail from resident #102's bed.
- The Director of Plant Operations was educated according to Manufacturers Guidelines on proper installation of bed rails.
- The Director of Plant Operations conducted a Bed Rail Entrapment Assessment throughout the building to identify any bed rail posing a risk of entrapment.
- The Executive Director of Operation obtained the manufacturer's guidelines for each type of bedrail in the facility, and they are compatible for use with the beds that we have.
- Any non-compliant bed rail was either fixed or replaced to meet assessment standards and proper installation according to the manufactures guide.
- The Director of Plant Operations will complete the Bed Rail Entrapment Assessment.
- The Director of Clinical Operations and/or designee will conduct an audit of bed mobility assessments to ensure proper evaluation and documentation.
- If the bed mobility assessment indicated that bed rails were not needed, they were removed by the Director of Plant Operations.
- The Director of Clinical Operations and/or designee will lead training sessions to ensure team members understand proper procedures for identifying and addressing bed rail concerns.
- Team members must immediately report malfunctioning, broken, or non-working equipment to their Supervisor and the Director of Plant Operations via phone and on maintenance log.
- New team members will be educated regarding reporting any broken equipment during orientation.
- The Executive Director completed educational training with the Director of Plant of Operations regarding the completion of the Bed Rail Entrapment Assessment per company policy.
- Nursing staff and department managers educated on acceptable gaps for zone 1 and zone 3.
- Nursing staff will document on the licensed medication administration record the checks have been completed.
- Any gaps larger than 4-3/4 will be reported to the on-call phone and the maintenance log.
- Documentation will be completed on the company form for the assessment.
- The Executive Director of Operations completed educational training with the Director of Plant Operations on the manufacturer's guidelines on bed rails installation for the Medline (FCE1232RSRN) and Joerns beds (F14SC).
- Charge nurses must accurately complete bed rail assessments and determine if rails are suitable for resident use.
- Charge Nurses educated on how to accurately complete bed rail assessments.
- New charge nurses will be educated regarding completing an accurate bed rail assessment during orientation according to manufacturers' recommendation.
- If an assessment indicates bed rails are recommended, the team member must notify both the Director of Clinical Operations and the Director of Plant Operations immediately.
- New charge nurses will be educated regarding immediate notification to the Director of Clinical Operations and the Director of Plant Operations during orientation.
- The Director of Clinical Operation and/or Designee will complete training on accident/incident prevention, including types of interventions put into place to prevent any further fall.
- The Clinical Reimbursement Coordinator will conduct an audit of resident care plans, ensuring appropriate documentation of bed rail concerns.
- Care plans will be updated to specify bed rail risks and potential entrapment hazards.
- The Director of Clinical Operations notified the Medical Director of immediate jeopardy and reviewed bed rail policy and procedure.
- This practice will be reviewed with the QA Committee to ensure no changes are needed to the current policy.
- All actions outlined in this plan will be monitored for ongoing compliance, reinforcing our commitment to providing a safe environment for residents.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Inaccurate bedrail care plans and missing ongoing assessments were identified for three residents. Two residents had bilateral enabler bars observed on their beds, but their last enabler-restraint assessments were outdated, and one resident had bilateral enabler bars with no order or ongoing assessment in the record. The residents had diagnoses including HTN, Parkinson's disease, depression, hyperlipidemia, and hemiplegia, and the facility policy required risk evaluation for bed rail use.
Inaccurate Bed Rail Assessments: The facility failed to complete ongoing accurate assessments for a resident’s right enabler side rail use. The resident had diagnoses including DM, hyperlipidemia, and depression, and the record showed quarterly bed rail evaluations stating bed rails were not recommended, yet a right enabler bar was observed on the bed and an RN confirmed the evaluations were not accurate.
Bed Rail Evaluations Not Completed Before Use The facility failed to complete bed rail evaluations for three residents who had bilateral 1/3 bed rails in use. One resident had severe cognitive impairment after a cerebral infarction and an incomplete bed rail evaluation remained in progress; another resident with hemiplegia, hemiparesis, and no decision-making capacity had bed rails ordered but no evaluation or care plan; and a third resident with a history of falls and bone density disorder had bed rails installed on readmission without a nursing evaluation. Staff confirmed the evaluations were not completed to assess appropriateness and entrapment risk.
Failure to assess entrapment risk and obtain informed consent for bed enabler bars. Two residents had bilateral enabler bars on their beds and were observed using them for positioning and bed mobility. One resident had dx including difficulty walking and muscle weakness; the other had repeated falls and generalized weakness. Surveyors requested documentation, but the facility could not provide entrapment zone measurements, and for one resident there was no informed consent documentation.
Failure to obtain informed consent for bed rails was identified for four residents. One resident had CVA-related deficits, blindness, muscle weakness, and an absent lower leg; another had Alzheimer’s disease, osteoporosis with fractures, reduced mobility, and muscle weakness; a third had adult failure to thrive and depression; and a fourth had adult failure to thrive, depression, and disorientation. Records included restraint or siderail assessments documenting quarter rails or upper side rails, but the EHRs lacked evidence of informed consent, and each resident was observed with upper side rails in place.
Improper Bed Rail Assessment and Use: The facility used grab bars as bed rails for multiple residents without completing the required pre-installation assessment process. Residents with diagnoses including muscle weakness, dementia, hemiplegia/hemiparesis, altered mental status, and fall history were observed with bilateral grab bars in place even when the BSA was incomplete, not recommended, or assessed for the wrong rail type. The QAN and DON stated grab bars are bed rails and that the required process was not followed.
Inaccurate Bedrail Care Plans and Missing Ongoing Assessments
Penalty
Summary
The facility failed to maintain accurate resident care plans and conduct ongoing accurate assessments for bedrail use for three residents. Facility policy stated that if a bed rail or side rail is used, the facility will evaluate the potential risks associated with bed rail use, including entrapment, before installation using the Bed and Bed Rail Safety Inspection Checklist. The report identified that the facility did not keep current assessments for Residents R2 and R14, whose beds had bilateral enabler bars observed during survey, and the last Enabler-Restraint Observation 2 assessment for each resident had been completed on 10/6/25. Resident R2 had diagnoses including high blood pressure, Parkinson's Disease, and anxiety, and had a physician order for a bariatric bed with bariatric mattress and bolster overlay and bilateral assistive handrails to aid with positioning, with placement checks every shift. Resident R14 had diagnoses including high blood pressure, hyperlipidemia, and depression, and had a physician order allowing grab/assist bars on the bed to promote independence and a sense of safety/security. Resident R160 had diagnoses including high blood pressure, hyperlipidemia, and hemiplegia, and bilateral enabler bars were observed on the bed, but the clinical record did not include an order or ongoing assessment for the enabler bar use, and the comprehensive care plan did not include measurable objectives, timetables, or specific interventions/services for the enabler bars.
Inaccurate Bed Rail Assessments
Penalty
Summary
The facility failed to conduct ongoing accurate assessments to ensure that bedrails were being used to meet a resident’s needs and to evaluate the risks associated with bedrail use for one of three residents. The facility policy dated 1/27/26 stated that the resident assessment must include an evaluation of alternatives attempted before installation or use of a bed rail and whether those alternatives were effective, and that assessment is to be completed at admission, re-admission, quarterly, annually, with significant change in condition, and when bed rails are added or removed. Resident R3 was admitted to the facility with diagnoses including diabetes, hyperlipidemia, and depression. The clinical record showed a physician order dated 2/23/26 for a right enabler side rail for positioning, and quarterly bed rail evaluations dated 3/18/26 and 6/19/26 both stated that bed rails were not recommended at that time. The current comprehensive care plan identified an ADL self-care deficit related to decline in overall function secondary to illness and included side rails (right enabler) for positioning. However, during an observation on 7/26/26 at 11:21 a.m., a right enabler bar was observed on the resident’s bed, and an RN later confirmed on 7/30/26 at 2:50 p.m. that the bed rail evaluations were not accurate.
Bed Rail Evaluations Not Completed Before Use
Penalty
Summary
The facility failed to ensure that a bed rail assessment was completed to evaluate risk for entrapment for three sampled residents who had bilateral 1/3 bed rails in use. The report states that the facility’s policy required a bed rail evaluation by a licensed nurse in collaboration with the IDT prior to use or installation of any bed rail on admission, readmission, or after a significant change in condition, including changes in mobility, cognition, behavior, or medical status. Resident 7 was admitted with diagnoses including unspecified sequelae of cerebral infarction and generalized muscle weakness. The MDS dated 5/12/2026 showed severe impairment in cognitive skills for daily decision making and extensive assistance needs for multiple ADLs and transfers. The care plan dated 6/11/2026 identified a potential for injury related to the use of bilateral 1/3 bed rails used as an enabler when in bed to assist with ADLs, transfers, and repositioning per resident/representative request, and it included evaluation of the ongoing need for bedrail use and assessment of entrapment risk prior to use. Observations on 7/21/2026 and 7/22/2026 showed the resident asleep in bed with bilateral 1/3 bed rails up. Review of the EMR on 7/22/2026 showed an order dated 6/12/2026 for the bed rails and a bed rail evaluation dated 5/21/2026 that was not filled out and remained in progress. RN 1 stated the evaluation was not completed and should have been completed to determine whether the bed rails were appropriate. Resident 104 was admitted with hemiplegia, hemiparesis following cerebral infarction affecting the left dominant side, and generalized muscle weakness. The H&P dated 7/16/2026 stated the resident did not have the capacity to understand and make decisions, had a fair prognosis for rehabilitation, and was on fall precautions. Observations on 7/21/2026, 7/22/2026, and 7/22/2026 showed the resident lying in bed with bilateral 1/3 bed rails up. Review of the EMR on 7/22/2026 showed an order dated 7/17/2026 for bilateral 1/3 bed rails used as an enabler when in bed to assist with ADLs, transfers, and repositioning per resident/representative request, but no bed rail evaluation or care plan for the bed rails. RN 1 confirmed that no bed rail evaluation or assessment and no care plan were present and stated the evaluation was needed to verify appropriateness of bed rail use. Resident 59 was admitted with a history of falling and a bone density disorder. The MDS dated [DATE] showed moderate impairment in cognitive skills for daily decision making and need for setup assistance with toileting hygiene, showering, lower body dressing, and footwear. On 7/22/2026, the resident was observed sleeping in bed with both 1/3 padded bed rails up. During record review, the MDS Nurse stated the resident had a physician’s order for the 1/3 bed rail on readmission but did not have a nursing bed rail evaluation prior to installation. RN 1 later reviewed the nursing bed rail evaluation and stated it had not been completed upon readmission and therefore the resident was not evaluated for entrapment risk. The facility’s P&P stated that bed rail risks, benefits, and need were to be evaluated prior to installation, including on admission, readmission, or after significant changes in condition.
Failure to Assess Entrapment Risk and Obtain Informed Consent for Bed Enabler Bars
Penalty
Summary
The facility failed to assess all potential risk areas for entrapment for two residents with enabler bars used as bed accident hazard devices, and failed to obtain informed consent for one resident's enabler bars. Resident 99 had diagnoses including difficulty walking and muscle weakness, a BIMS score of 15 indicating no cognitive impairment, and care plan interventions that included assist rails and bilateral grab bars to help with turning, repositioning, and bed mobility. During observation, bilateral enabler bars were attached to the resident's bed, and the resident stated he used them to help position himself. When surveyors requested documentation of informed consent, entrapment zone measurements, and risk assessments, the facility provided a nursing acknowledgement form dated January 17, 2025, but it did not include entrapment zone measurements, and the facility later stated it could provide no further documentation showing the potential entrapment zones were assessed. Resident 86 had diagnoses including repeated falls, a BIMS score of 14 indicating no cognitive impairment, and a care plan intervention that included grab bars on the bed to assist with bed mobility related to generalized weakness. During observation, bilateral enabler bars were present on the resident's bed, and the resident stated she used them to get in and out of bed. When surveyors requested documentation related to the enabler bars, the facility provided a nursing physical device review form dated March 23, 2026, but it did not contain entrapment zone measurements or documentation of informed consent. The facility later stated it could provide no further documentation showing the potential entrapment zones were assessed or that informed consent was obtained for the enabler bars.
Failure to Obtain Informed Consent for Bed Rails
Penalty
Summary
The facility failed to obtain informed consent from residents or their legal representatives before installing bed rails for four residents. R10 had diagnoses including cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting the right non-dominant side, blindness in the right eye, muscle weakness, and acquired absence of the right leg below the knee. The Restraint Use Assessment-V3 dated 01/09/2026 documented quarter bed rails to enhance bed mobility and stated they were not considered a restraint, but the EHR lacked evidence of informed consent. R10 was observed on 07/20/26 at 09:15 AM with upper side rails on each side of the bed. R14 had Alzheimer's disease, osteoporosis with femur fracture, fracture of the lower end of the left humerus, reduced mobility, muscle weakness, and difficulty walking, and the EHR lacked evidence of a bed rail assessment and informed consent; R14 was observed on 07/20/2026 at 08:29 AM with upper side rails on each side of the bed. R1 had adult failure to thrive and depression, and two Restraint Use Assessment-V3 entries documented quarter rails to enhance independence with bed mobility and transfers, but the EHR lacked evidence of informed consent; R1 was observed on 07/20/2026 at 09:25 AM with upper side rails on each side of the bed. R39 had adult failure to thrive, depression, and disorientation; the Siderail Assessment V1.0 dated 12/16/2025 documented impaired memory, cognition, or decision-making and conditions requiring increased safety measures, but the EHR lacked evidence of informed consent. R39 was observed on 07/20/2026 at 09:56 AM with upper side rails on each side of the bed.
Improper Bed Rail Assessment and Use
Penalty
Summary
The facility failed to ensure that bed rails or grab bars were properly assessed before installation for four sampled residents. The report states that the facility used the terms grab bars and bed rails interchangeably, and that the residents had orders for bilateral grab bars as aids to bed mobility, turning and repositioning, and transfers. The facility’s own policy required an interdisciplinary assessment, physician consultation, informed consent, entrapment assessment, and care plan inclusion before bed rail use. For Resident 54, the record showed diagnoses including muscle weakness, dementia, and hemiplegia/hemiparesis. The resident’s H&P stated the resident did not have capacity to understand and make decisions, and the MDS showed severe cognitive impairment and dependence for mobility and ADLs. Although the BSA dated 7/4/2026 stated that bed rails were not recommended by the IDT and physician, the resident was observed with bilateral grab bars in place. The QAN stated the grab bars were bed rails and that staff still applied them despite the BSA. For Resident 25, the record showed diagnoses including hemiplegia/hemiparesis and muscle weakness, and the H&P stated the resident could make needs known but could not make medical decisions. The BSA was incomplete and had no recommendation for bed rail use, while the resident was observed with bilateral upper grab bars on the bed. For Resident 26, the record showed reduced mobility, muscle weakness, and altered mental status, with the H&P stating the resident could make needs known but could not make medical decisions. The BSA stated grab bars were not recommended by the IDT and physician, yet the resident was observed sleeping in bed with bilateral grab bars in place and later again with bilateral upper grab bars on. For Resident 42, the record showed muscle weakness, history of falling, and hemiplegia/hemiparesis. The H&P stated the resident had capacity to understand and make decisions, and the MDS showed moderate cognitive impairment and a recent fall. The physician’s order was for bilateral grab bars, but the BSA assessed for 1/2 rails instead. The resident was observed in bed with bilateral grab bars on, and the QAN stated the assessment was for the incorrect bed rail type. The DON and QAN both stated that grab bars are an example of a bed rail and that the proper assessment process was not followed.
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