Incomplete Bed Entrapment Assessments for Residents Using Bed Rails
Summary
Surveyors identified that the facility failed to ensure accurate and complete entrapment assessments for residents using bed rails and grab bars. Specifically, for several residents, the Bed System Measurement Device Test Results Worksheets did not document whether Zone 7—the space between the head or foot board and the mattress end—was measured or whether it passed or failed the entrapment assessment. This omission was observed across multiple sampled and nonsampled residents, despite the presence of physician orders for bed rails or grab bars for mobility, turning, or repositioning. The facility's policy required regular inspection and assessment of all bed frames, mattresses, and bed rails to identify possible entrapment areas, but the documentation was incomplete for the required zones. Observations included residents in bed with bilateral grab bars or side rails elevated, and in some cases, residents were not present but their beds were observed with the rails in use. Medical record reviews confirmed that these residents had orders for the use of bed rails or grab bars, and in some cases, care plans addressed the risk of entrapment. However, the maintenance records failed to show complete measurements for all required entrapment zones, particularly Zone 7. Interviews with the Maintenance Director confirmed discrepancies and acknowledged that Zone 7 was not consistently assessed or documented, and in some cases, units of measurement were missing for other zones as well. The deficiency was further substantiated by interviews with facility leadership, including the ADON and DON, who acknowledged the findings. The lack of complete and accurate entrapment assessments had the potential to negatively impact residents by increasing the risk of entrapment, serious injury, or death, as described in the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment. The facility's failure to adhere to its own policies and federal requirements for bed safety assessments was evident in the incomplete documentation and inconsistent measurement practices.
Plan Of Correction
2. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. All residents were potentially affected by this deficient practice. On 7/23/2025, the Maintenance director audited all residents' beds for entrapment measurement of zone 7, and all 182 residents were found to have issues related to the form use not reflecting zone 7 if it fails or passes the entrapment measurement. The Maintenance team immediately re-measured all zone 7 in resident beds, and the entrapment measurement form was revised to reflect zone 7 measurement of fail or pass. All zone 7 entrapment measurements passed. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: The Administrator or designee will oversee this process and compliance. Maintenance will measure zone 7 for entrapment and make sure it reflects on the measurement for the entrapment form. Any bed not in compliance with zone 7 entrapment will be removed. The Administrator will review entrapment records randomly for compliance for 4 weeks and monthly thereafter. 4. Facility plans to monitor the effectiveness of the corrective actions and sustain compliance; integrate QA process: The Administrator will monitor the effectiveness of the process and report any findings, which will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Torn Mattress Left in Resident Room: A resident’s bed mattress was observed with punctures exposing internal materials and with dips and lumps on the sleeping surface while the bed was unmade. The resident said staff had known about the mattress for over a year and that it was very uncomfortable. The HSKP supervisor said staff usually report worn mattresses, and the administrator said new mattresses had been ordered but was unsure how this one was missed.
Failure to inspect bed systems for entrapment hazards: The facility did not maintain a regular program to inspect bed rails, mattresses, and frames or measure FDA entrapment zones. The ML stated annual bed checks focused on electrical components and function, but entrapment measurements were not being done, and the DON stated all residents had bed rails because they came on the bed. Multiple residents were observed with raised bed rails, including combinations of upper and lower rails, and the facility policy called for regular bed inspections and individual bed rail evaluations.
A facility failed to ensure safe inspection and fit of resident beds and air mattresses. One resident with multiple chronic conditions had an air mattress with an approximately five-inch gap between the mattress and foot board on repeated observations, and staff were unclear who was responsible for correcting it. Another resident fell from bed when a broken clip securing the air mattress strap to the frame allowed the bed to lift; surveyors later observed the mattress was too wide for the bedframe, with about five inches hanging over the side and not fully supported.
Bed rail safety checks showed Zone 1 gaps of 7 inches for three residents, exceeding the FDA maximum of 4 3/4 inches. One resident had Bell’s palsy, falls history, reduced mobility, and cognitive impairment; another had Alzheimer’s disease, dementia, a tibia fracture, and needed max assist for bed mobility; and a third had quadriplegia and needed max assist for bed mobility. Observations found large square openings in the rails, a mattress separated from the frame, and staff interviews showed the Housekeeping Supervisor measured the rails while nursing leadership kept the forms and was responsible for compliance.
The facility failed to maintain a routine process to inspect bed frames, mattresses, and bed rails for possible entrapment. Record review showed the bed inspection form addressed bed height and wheelchair cushion securement, but did not include checks of frames, mattresses, or rails. The ADMIN and MAINT both confirmed there was no checklist or routine maintenance program for these inspections unless a work order was submitted.
Missing Bed Rail Inspection Documentation: The facility failed to complete and/or maintain routine bed rail inspection records for all residents with side rails. A resident with bilateral half rails used for repositioning and safety due to frequent falls out of bed was observed with upper quarter-length rails, and maintenance staff from a sister facility later checked the rails without prior facility documentation. An undated bed entrapment inspection form showed 10 beds passed, but it did not identify who completed the assessments.
Torn Mattress Left in Resident Room
Penalty
Summary
The facility failed to maintain environmental equipment safety, comfortability, and appearance for one resident’s bed mattress. During observation, the resident was sitting in a wheelchair while the bed was unmade, and the exposed blue mattress had a moderate amount of brown/tan punctures on the outer layer that exposed internal mattress materials. Dips and lumps were also noted on the sleeping surface. The resident stated that staff had known about the mattress for over a year, that it looked terrible, and that it was very uncomfortable. The housekeeping supervisor stated that staff usually notify him when mattresses are dirty or worn and that nursing staff, housekeeping staff, and maintenance usually work together when they see a mattress that needs to be changed. The housekeeping supervisor later entered the room and exchanged the mattress after overhearing the resident’s comments. The administrator stated that new mattresses had been ordered and was not sure how this mattress had been missed. The resident rights documents cited in the report state that residents have the right to dignity, respect, quality care, and services or items included in the plan of care.
Failure to Inspect Bed Systems for Entrapment Hazards
Penalty
Summary
The facility failed to implement a regular maintenance program to ensure bed systems, including bed rails, mattresses, and frames, were inspected for safety and potential entrapment hazards. The report states that the facility did not conduct routine assessments of mattress fit or measure potential entrapment zones in accordance with FDA guidance, despite having a policy that called for regular inspection of all bed systems and individual bed rail evaluations. The Maintenance Leader stated that annual bed inspections were performed for electrical components and bed functionality, but entrapment measurements were not being done, and later stated that FDA-recommended testing had been done in 2023 but not since. Observations showed multiple residents using bed rails in their rooms and beds. R2 was repeatedly observed in bed with raised 1/3 bed rails, including two rails at the head of the bed and, at times, a rail at the foot of the bed; R2 stated he thought the rails were there to keep him from falling out of bed. R3, R5, R8, R11, and R12 were also observed in bed with combinations of raised 1/3 rails, including some observations with rails at both the head and foot of the bed. Additional residents, including R4, R9, R13, R22, R23, R25, R26, and R27, were observed with bilateral upper bed rails raised, and some were also observed with a lower rail raised. The DON stated that all residents had bed rails because they came on the bed. The facility policy titled Safe and Effective Bed Rail Use stated that the facility would identify and reduce safety risks associated with bed rail use through regular bed maintenance and individual bed rail evaluations, including regular inspection of rails, frames, mattresses, and operational components. The policy also described FDA potential zones of entrapment and dimensional recommendations, but the maintenance records reviewed did not show that entrapment measurements were performed as part of an ongoing process.
Unsafe Bed and Mattress Inspection and Attachment
Penalty
Summary
The facility did not ensure that resident beds, mattresses, and air mattress attachments were properly inspected for safety. Surveyors observed that R110, who had diagnoses including polyneuropathy, spinal stenosis, peripheral vascular disease, unspecified visual loss, and a history of falling, had an air mattress with an approximately five-inch gap between the mattress and the foot board on multiple observations. Staff interviewed during the survey gave inconsistent responses about who was responsible for ensuring the mattress fit the bed frame and who would address the gap, and the Director of Nursing later placed a spacer between the mattress and bed frame. The facility was not able to provide a mattress policy when requested. The facility also failed to ensure safe bed and mattress attachment for R59 after a fall from bed. The incident report documented that while R59 was receiving cares, the bed suddenly lifted on the window side and R59 fell to the floor, sustaining a lumbar spine fracture. The investigation identified a broken plastic clip securing the air mattress strap to the bed frame on the left side. The maintenance director stated he did not routinely check beds after installation and relied on nursing staff to report problems. During survey observations, R59’s mattress was found to be too large for the twin-size bedframe, with approximately five inches of the mattress hanging over the left side and the mattress not fully supported by the frame. Surveyors observed that the mattress could be easily moved from the bed frame because it was not appropriately attached and did not fit in the bed frame brackets. Facility leadership acknowledged they had not been in the room to observe the bedframe before the surveyor’s findings, and the maintenance director confirmed the bedframe had not been routinely checked by maintenance.
Bed Rail Gap Measurements Exceeded Allowed Standards
Penalty
Summary
The facility failed to maintain an effective program to identify possible resident entrapment when side rail gap measurements for three residents exceeded the maximum allowed standards. Surveyors reviewed FDA guidance and facility policies that required bed frames, mattresses, and bed rails to be checked for compatibility and for all gaps to remain within safety dimensions. The facility’s Bed Rail Safety Check form listed a maximum Zone 1 gap of 4 3/4 inches, yet the form did not identify allowances for Zones 5, 6, or 7. Resident #63 had diagnoses including Bell’s palsy, history of falls, lack of coordination, reduced mobility, and cognitive impairment involving function and awareness. The resident’s quarterly MDS showed the resident was cognitively intact and independently mobile. The resident had consent and a physician order for bilateral upper half rails to assist with repositioning and bed mobility. A quarterly bed rail safety check documented Zone 1 measurements of 7 inches on each side of the bed, exceeding the allowed maximum by 2 1/4 inches. During observation, the resident was in bed with the right upper side rail raised, the mattress was crooked and separated from the bedrail, bare metal frame was exposed, and the bedrail had a large square opening in the middle. The Housekeeping Supervisor later measured the rail and found a 7 inch by 7 inch opening. Resident #2 had diagnoses including cellulitis of the left lower limb, Alzheimer’s disease, dementia, osteoarthritis in both knees, violent behaviors, muscle weakness, fracture to the right tibia, and reduced mobility. The resident’s annual MDS showed severely impaired cognition for decision making and substantial to maximal assistance needs for bed mobility and transfers. The care plan directed half side-rails up x 2 per physician orders for safety during care provision and to assist with bed mobility. A completed bed rail safety check documented Zone 1 measurements of 7 inches on each side of the bed, but pass/fail was not indicated. Observations showed the resident in bed with both side rails raised and each rail had a large square opening in the middle. The resident stated the side rails were used to help reposition in bed, and the Housekeeping Supervisor later measured both upper rails at 7 inches by 7 inches. Resident #7 had diagnoses including quadriplegia, anxiety, and depression. The resident’s quarterly MDS showed cognitive intactness for decision making and substantial to maximal assistance needs for bed mobility and transfers. The care plan directed half side-rails up x 2 for safety during care provision and to assist with bed mobility, and the informed consent stated a half partial rail was to be used at all times when the resident was in bed. A bed rail safety check documented a Zone 1 measurement of 7 inches on the left side, exceeding the allowed maximum by 2 1/4 inches, with pass/fail not indicated. During observation, the resident’s bed was pushed against the wall with a half bedrail on the left side, and later the Housekeeping Supervisor measured one upright rail with a large square opening measuring 7 inches by 7 inches. Staff interviews showed the Housekeeping Supervisor performed the measurements, nursing leadership kept the forms, and the MDS Coordinator, DON, and Administrator were identified as responsible for compliance.
Lack of Routine Bed Entrapment Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, if any, as part of a maintenance program to identify possible entrapment areas. Record review of the occupational therapy bed inspection form showed inspection of bed height, securement of a wheelchair cushion, and issues identified with bed height and seat cushion, but it did not include inspection of frames, mattresses, or rails for possible entrapment. During interview, the Administrator confirmed the facility did not have a checklist or routine maintenance process to inspect bed frames, bed mattresses, and bed rails, and stated that if there was an issue with bedrails, a work order was placed and repaired at that time. The Maintenance Director also confirmed there was no routine maintenance program in place to inspect bed frames, bed mattresses, and bed rails unless a work order was submitted.
Missing Bed Rail Inspection Documentation
Penalty
Summary
The facility failed to complete and/or maintain documentation of routine bed rail inspections for 10 of 10 residents with side rails. The report states the facility had a census of 78 residents. Resident #32 had bilateral half rails used to aid in repositioning and safety due to frequent falls out of bed, with a care plan goal initiated on 6/27/25 for the resident to remain free of falls out of bed and to assist with repositioning through the review date. A care plan intervention also directed staff to assist the resident with independence in repositioning. On 5/20/26, the Administrator observed that a resident had both upper quarter-length rails and stated the Housekeeping and Laundry Supervisor currently oversaw maintenance due to a recent staff changeover. Later that day, the Maintenance Director and Maintenance Assistant from a local sister facility were in Resident #32's room evaluating the bed rails, and one rail was removed and placed on the floor. They presented empty maintenance inspection sheets and stated facility staff had not provided prior documentation of bed rail assessments, and corporate management had called them in that day to check all bed rails in the facility. They stated they did not see anything wrong with Resident #32's bed rails, but were not used to this type and were not verifying that the entrapment zone measurements were correct. The Administrator later provided an undated Bed Entrapment Inspection form showing 10 resident beds passed, but the form did not identify who completed the assessments.
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