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:
Loose Bed Assist Bar Left in Place on Resident’s Bed: A resident with anxiety, intact cognition, and moderate assistance needs for bed mobility had bed rail assessments that changed over time, with later documentation stating siderails/assist bars were not indicated. Despite this, two assist bars remained on the bed, and the left bar was observed to be loose and freely moving away from the bed. Staff reported the resident did not use the bars, maintenance did not perform monthly checks of bed positioning devices, and administrative staff were uncertain about inspection requirements.
Improperly Fitted Specialty Mattress Created Bed Gap: A resident with severe cognitive impairment and extensive assistance needs was observed on a low air loss mattress that did not fit the bed frame well, leaving an approximately six-inch gap between the grab bar and the mattress. The QAN and MS both stated the mismatch created an entrapment risk, and the mattress supplier confirmed the mattress was 36 inches wide while the bed frame had width extensions from the original mattress. The resident reported difficulty getting up from the bed and discomfort while sleeping.
A resident reported that a circular bed rail was loose before the incident, and staff were aware of the problem but did not ensure it was repaired. During incontinence care, the rail bent flat instead of staying upright, causing the resident to fall to the floor and sustain a femur fracture with severe hip and knee pain.
Two bariatric residents had bed-related issues affecting comfort and safety. One resident had a mattress that was too large for the bariatric bedframe and said she felt unsafe and had asked for bedrails that were never provided. Another resident had a properly fitted mattress that was old, lumpy, and uneven, causing back pain and poor sleep. Staff were unaware of the concerns, and the DON and Administrator acknowledged the bed and mattress problems during interview.
Loose Bed Grab Bars: A resident’s bilateral bed grab bars were found to be loosely installed and moving sideways, backward, and forward while the resident used them daily to get out of bed and reposition. The Maintenance Director verified that the screws at the bases of both grab bars were loosely attached to the bed frame, and the facility’s maintenance policy required equipment to be kept safe, operable, and free from hazards.
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.
Loose Bed Assist Bar Left in Place on Resident’s Bed
Penalty
Summary
The facility failed to ensure a resident’s bed was in safe condition. The resident had a diagnosis of anxiety, a BIMS score of 13 indicating intact cognition, and required moderate assistance with bed mobility. Her care plan stated she preferred bed rails to help her reposition in bed, and bed rail assessments documented at different times that siderails/assist bars were indicated and served as an enabler to promote independence, while later assessments documented that siderails/assist bars were not indicated. During observation, the resident’s bed had a bed assist bar on each side in the upright position, and the left bed assist bar was quite loose and freely moved away from the bed. The loose condition was observed again the next day. A CMA reported the resident did not use the bed assist bars and staff did not realize they were loose. Maintenance staff reported he did not complete a monthly check of bed positioning devices and that once the device is applied to a resident’s bed, it is removed at discharge. Administrative staff reported they were uncertain whether the bed assist bars were required to be inspected, and an administrative nurse stated she was not aware of the later bed rail assessments documenting the rails were not required.
Improperly Fitted Specialty Mattress Created Bed Gap
Penalty
Summary
The facility failed to ensure that a low air loss mattress fit the bed frame size and that there were no gaps between the grab bar and the mattress for one resident. During observation, the mattress was noted to be inflated with soft and firm sections and did not fit the bed frame well, with an approximately six-inch gap between the grab bar and the mattress. The Quality Assurance Nurse stated the mattress did not fit the bed frame and that it was an entrapment risk. The resident involved had been admitted after lumbar spine fusion surgery and had diagnoses including acute pulmonary edema, depression, legal blindness, bipolar disorder, and a right artificial knee joint. The Minimum Data Set indicated severely impaired cognitive function and that the resident required maximal assistance with dressing, toileting, bathing, standing, and transferring. During interviews, the resident stated it was not convenient to get up from the mattress, slept badly, could not be comfortable, and had to scoot to the edge of the bed to get up. The Maintenance Supervisor stated the mattress was smaller than the bed frame because the bed frame had width extensions for the original mattress, and that the width extensions should have been removed before installation so the mattress would fit. The mattress supplier representative stated the model number indicated a 36-inch-wide mattress. The DON stated that a resident could get hurt if there was a gap and that nurses and maintenance personnel should check bed safety. The facility's bed safety policy required inspection of beds and related equipment and review of gaps within the bed system, and the bed frame manual warned that an improperly fitted mattress could result in injury or death.
Loose Bed Rail Failed During Care
Penalty
Summary
The facility failed to ensure that a circular bed rail was maintained in safe working condition. A review of the facility policy showed that maintenance personnel and clinical staff were responsible for bed safety, and that beds and bed rails were to be inspected regularly to ensure compliance with safety standards. The maintenance director and clinical staff were unable to provide documentation of safety checks for the bed rails. Resident #1 reported that the bed rail on her bed was loose before the incident and that she had told staff about it. A nurse aide documented on the routine maintenance log that the resident’s bed rail was broken, and a nurse stated she was told the rail was loose and observed that it was loose. However, the nurse aide did not enter a work order, and the nurse assumed the maintenance director would see the log and repair the rail. The maintenance director stated he did not see the entry, did not receive notice of a work order, and acknowledged that he did not always check the clipboard logs daily or complete thorough monthly inspections as required. During incontinence care, Resident #1 was holding onto the circular bed rail when it bent and rotated flat instead of staying upright. The resident fell to the floor and later stated the rail collapsed and the event was traumatic. Nursing documentation noted the resident was found on the floor with the rail bent down toward the ground and complained of left hip and knee pain. Emergency department records showed the resident had severe pain and was diagnosed with a nondisplaced medial femoral condylar fracture. The resident stated the fall could have been avoided if the bed rail had been fixed.
Incompatible Bariatric Beds and Worn Mattress
Penalty
Summary
The facility failed to ensure that the bed rails, mattress, and bed frame were compatible for two bariatric residents. One resident had a bariatric bedframe with a mattress that extended approximately 4 to 6 inches beyond the frame. The resident stated she felt unsafe in the bed and had asked multiple times for bedrails, but they were not provided. The resident also stated she had not had any falls or other accidents, but remained uncomfortable and concerned about rolling off the bed. The second resident had a bariatric bedframe with a properly fitted mattress, but the mattress was described by the resident as old, lumpy, and uneven. The resident stated the mattress caused increased back pain and disturbed sleep because she had to keep turning to find a comfortable position. The resident also stated she had reported the mattress concerns to the Administrator, but nothing was done. Observation confirmed the mattress was lumpy with an uneven structure. Record review showed both residents were bariatric with significant mobility limitations and multiple diagnoses, including obesity-related conditions. Their care plans did not include focus or interventions related to bed mobility, safety, or comfort. Staff interviews reflected they were unaware of the mattress and bed concerns, and the Administrator stated the facility had used the wrong mattress size for one resident and that assist rails delivered for that bed did not fit the frame. The Administrator also stated the second resident had the same mattress for years and had only recently started complaining.
Loose Bed Grab Bars
Penalty
Summary
The facility failed to ensure the bilateral grab bars attached to Resident 137’s bed were properly installed. During an observation, Resident 137 was awake and lying in bed and stated she used the grab bars daily to get out of bed and reposition herself from lying to sitting, but that they were moving. The resident also stated they could have been fixed so they would be firm and not move. On inspection, the two grab bars were observed to move sideways, backward, and forward. The Maintenance Director verified the movement and determined that the screws at the bases of both grab bars were loosely attached to the bed frame. The resident was admitted to the facility on 12/26/24, and the facility’s maintenance policy stated that equipment was to be maintained in a safe and operable manner and free from hazards.
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.
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