Incomplete and Inaccurate Bed Entrapment Assessments for Residents Using Grab Bars
Penalty
Summary
The facility failed to ensure that entrapment assessments for bed grab bars were accurate and complete for three residents who used these devices for mobility and positioning. Observations and interviews confirmed that these residents regularly used bilateral grab bars while in bed, and their medical records included physician orders for the use of these devices. However, review of the Bed Entrapment assessments for these residents revealed that critical information was missing, specifically whether certain entrapment zones (Zones 6 and 7) passed or failed the assessment. Additionally, the required quarterly reassessments of bed entrapment risk were not completed for these residents. Facility policy required that all beds, bed rails, and mattresses be inspected to ensure no gaps wide enough to entrap a resident’s head or body, with inspections documented and reported to facility leadership and the QAPI committee. Despite this, the maintenance staff did not consistently communicate assessment results to licensed nurses, and the Maintenance Director was unfamiliar with the assessment forms being used. The documentation for the entrapment assessments was incomplete, and there was no evidence that the assessments were performed at the required quarterly intervals. Interviews with facility staff, including the Maintenance Director, ADON, and DON, confirmed the lapses in both the completion and documentation of the entrapment assessments. The staff acknowledged that the assessments were not performed as required and that the forms did not indicate whether the relevant zones passed or failed. These failures were identified through observation, record review, and staff interviews, and were acknowledged by facility leadership.