Incomplete Bed Entrapment Assessments for Residents Using Bed Rails
Penalty
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