Failure to Ensure Bed Rail Availability and Staff Awareness
Penalty
Summary
A deficiency was identified when a resident was observed resting in bed with the upper right bed rail missing. Staff, including the Environmental Services Supervisor, were unaware of the missing bed rail until it was brought to their attention. The Environmental Services Supervisor confirmed the bed rail was missing and speculated that the resident's wife may have removed it. The resident's medical record indicated significant health concerns, including a history of malignant brain tumor, dependence on supplemental oxygen, reduced mobility, muscle contractures, and tracheostomy status. The resident was documented as being totally dependent on staff for personal hygiene and movement, and had a signed bed rail consent form indicating the use of bed rails for fall prevention. The absence of the bed rail was not noticed or addressed by staff until questioned by the surveyor, and the bed rail was later found in the resident's bathroom and reattached. This incident demonstrated a failure to ensure the environment was free from accident hazards and that adequate supervision was provided to prevent accidents, particularly for residents who are dependent on staff and require bed rails for safety.