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:
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.
Unsafe Bed Frame, Mattress, and Bed Rail Conditions: Two residents had unsafe bed setups. One resident with CHF, obesity, chronic respiratory failure, and dependence for bed mobility had an undersized mattress that exposed metal bed frame and left gaps between the mattress and quarter side rail; when turned, the resident’s foot contacted the sharp metal frame. Another resident with dementia, schizophrenia, prior CVA/TIA, and dependence for bed mobility had a loose left quarter rail and no right rail, despite orders for bilateral upper quarter rails.
Nonfunctional Bed Frames and Electric Bed Not in Good Repair: The facility failed to ensure that several residents' bed frames had working manual lift mechanisms and that one resident's electric bed was in good repair. During observation, an electric bed control would not function even after the cord was found and reconnected, and multiple manual crank bed frames for other residents were observed not to work properly. A CNA stated the crank handles could not lift the beds, and the Maintenance Director acknowledged some crank handles were rusted and had been repaired with oil spray.
Failure to Inspect U-Bar as Part of Regular Bed Safety Program: A resident with severe cognitive impairment and transfer assistance needs had a u-bar on the bed for transfers, but the facility did not include the u-bar in its regular maintenance inspection program. Surveyors observed the u-bar in place, reviewed records showing the device was ordered and used for transfers, and found no evidence that maintenance had regularly inspected it. The maintenance supervisor stated u-bars were not routinely inspected, and the DON/administrator were unaware of why regular inspections were not being done.
Facility staff failed to conduct and document routine inspections of resident bed frames, mattresses, and bed rails. Surveyors reviewed maintenance logs and found they reflected various repairs but did not show the required monthly bed inspections. The Administrator stated that routine inspections were not being conducted, and the DON provided a policy that included a 12-point monthly bed inspection checklist.
Bed mattresses did not fit the bed frames for three residents, leaving exposed gaps at the foot of the bed and between the mattress and side rail. One resident reported a foot had gotten caught in the gap more than once, another had a 7-inch gap at the head and side of the bed, and review of bed assessments showed the foot end had not been assessed for possible entrapment.
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.
Unsafe Bed Frame, Mattress, and Bed Rail Conditions
Penalty
Summary
The facility failed to ensure resident beds were properly maintained in a safe manner for two residents. One resident had diagnoses including congestive heart failure, obesity, chronic respiratory failure, venous insufficiency, depression, atrial fibrillation, type 2 diabetes mellitus, hypertension, and venous thrombosis and embolism, and was dependent on staff for activities of daily living including bed mobility. Although the resident’s care plan included quarter upper bilateral side rails for bed mobility and transfer ability, observation showed the mattress was undersized, leaving approximately four inches of exposed metal bed frame on the right side and a four-inch gap between the mattress and the right upper quarter side rail. When staff turned the resident, the resident’s right foot contacted the metal bed frame with sharp edges, and the LPN verified the mattress was undersized and exposed the frame with a gap between the rail and mattress. The Maintenance Director later measured gaps of six inches at the foot of the bed, four inches in the middle, and three inches between the rail and mattress, and stated he was unaware when the bed and mattress were assessed for proper fit. A second resident had diagnoses including dementia, transient ischemic attack, cerebral infarction, spinal lumbar stenosis, anxiety disorder, paranoid schizophrenia, major depression, intellectual disability, congestive heart failure, and hypertension, and was dependent on staff for bed mobility and transfers with a history of falls. The resident’s care plan and physician order included upper quarter bilateral side rails for bed mobility and transfer ability enabler. Observation showed the bed had a loose quarter side rail on the left side and no quarter side rail on the right side. CNAs verified the left rail was loose and the right rail was missing, and stated the resident used the side rails when being positioned in bed and was fearful of falling without them. Later, an RN also verified the left bed rail was loose and the right bed rail was missing, and the Maintenance Director stated he was unaware of the loose and missing bed rail.
Nonfunctional Bed Frames and Electric Bed Not in Good Repair
Penalty
Summary
The facility failed to ensure that residents' bed frames had functioning manual lift mechanisms to raise or lower the bed and failed to ensure that a resident's electric bed was in good repair. During observation with CNA staff, R7's electric bed frame control was not functioning; the CNA looked under the mattress, found the electric cord, and tried to connect it to the bed frame, but the bed still did not work. The CNA stated she would notify Maintenance staff. During the same observation, several other bed frames with manual crank handles, including those for R3, R4, R5, and R6, were observed not to work properly. A CNA stated that if the crank handle cannot lift the bed, staff must bend too much to help residents who need assistance. The Maintenance Director stated that some bed frames had been repaired after nursing staff notified him, that some crank handles had rusted ends, and that he used oil spray to make stiff crank handles work properly. The Administrator stated the facility had started purchasing more electric beds and would continue replacing old bed frames with new beds.
Failure to Inspect U-Bar as Part of Regular Bed Safety Program
Penalty
Summary
The facility failed to ensure inspection of u-bars was included in its regular maintenance program for Resident #38, who was identified as using a u-bar on the right side of the bed. The resident had a physician order dated 06/14/25 stating that a u-bar may be used to assist with transfers, and a quarterly assessment dated 04/17/26 showed a BIMS score of four, indicating severe cognitive impairment and the need for partial to moderate assistance for transfers from chair to bed. On 05/05/26, surveyors observed the resident’s bed with a u-bar on the right side, and later observed the resident in bed with eyes closed and the u-bar still in place. The facility’s Bed Safety policy stated that maintenance staff should inspect all beds and related equipment as part of the regular bed safety program to identify risks and problems, including potential entrapment risks. However, review of the electronic clinical record did not show that the u-bar had been inspected as part of the maintenance program. The maintenance supervisor stated that u-bars were not regularly inspected and were only installed and removed when instructed, and the administrator stated they did not know why regular inspections were not being conducted.
Failure to Conduct and Document Routine Bed Inspections
Penalty
Summary
Facility staff failed to conduct regular inspections of resident bed frames, mattresses, and bed rails, and the facility did not maintain records showing that routine bed inspections were completed. Review of anonymous complaint #2963504 led surveyors to request the facility’s bed inspection logs. The Administrator stated that routine inspections were being done but that the facility had not kept very good records. During interview, the DON and Administrator provided maintenance logs dated from 1/2025 through 4/8/2026, which showed various repair concerns for equipment and other areas, but did not reflect routine inspection of the facility’s beds as required. The Administrator stated that maintenance checked bed motors when making repairs and confirmed that maintenance was not conducting routine inspections of the beds. The DON also provided the facility policy and procedure for equipment and utilities management, which included a checklist for a 12-point monthly bed inspection.
Bed Mattresses Did Not Fit Bed Frames, Creating Entrapment Gaps
Penalty
Summary
The facility failed to ensure that bed mattresses were compatible with bed frames and that areas of possible entrapment were identified for three residents. One resident was observed lying in bed with the bed frame larger than the mattress, leaving several inches exposed at the foot of the bed; the resident stated that a foot had gotten caught in the gap more than once over the past several months when attempting to get up to the bathroom at night. During a later observation with the Maintenance Director, the mattress was confirmed to leave a 5-inch gap at the foot of the bed. A second resident was observed with a 7-inch gap between the mattress and the side rail at the head of the bed, and the resident stated the mattress and bed frame had been used for the past month and that the resident had not rolled off the exposed bedframe and could independently reposition in bed. A third resident was observed with the bed frame larger than the mattress, leaving several inches exposed at the foot of the bed. Later observations with the Maintenance Director confirmed a 5-inch gap at the foot of the bed. Review of the bed assessments showed no evidence that the foot end of the beds had been assessed for the potential entrapment of body parts.
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