Failure to Ensure Proper Bed Rail Installation, Assessment, and Maintenance
Penalty
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.