Failure to Assess and Monitor Bed Rail Entrapment Risk
Penalty
Summary
The facility failed to properly assess and monitor the risk of entrapment associated with side rail use for two residents. For one resident, repeated observations showed a significant gap between the mattress and the side rail, but the facility's bed rail assessments did not include evaluation for entrapment risk. Interviews with the DON, Environmental Services Director, and Therapy Director revealed confusion over which department was responsible for conducting safety checks, and it was acknowledged that entrapment assessments were not being performed. The facility's policy also did not address the need to assess for entrapment risk or ongoing safety monitoring. For the second resident, side rails were in use per physician order to assist with bed mobility, and the care plan included monitoring for injury or entrapment. However, the facility's bed rail assessments did not include evaluation for entrapment risk. Documentation indicated that the resident was not using the side rails for mobility and that removal would be attempted, but there was no evidence of follow-up or reevaluation after this recommendation. The resident continued to have orders for side rail use, and the facility was unable to provide documentation of ongoing assessment or reevaluation regarding the need for side rails. The facility's policy required completion of a side rail assessment form before use and periodic reassessment, but the assessments conducted did not address entrapment risk. There was also a lack of clear documentation and follow-through when recommendations for removal of side rails were made. These deficiencies were identified through observations, record reviews, and staff interviews.