Failure to Inspect Beds and Assess Entrapment Risks
Penalty
Summary
The facility failed to inspect beds and identify risks for entrapment for two residents who were dependent on staff for bed mobility. Observations revealed that one resident had a one-half side rail on their bed, and reviews of both residents' care plans and bed rail assessments showed that inspections of the beds or assessments for entrapment risks were not included during evaluations. The bed rail assessments were conducted on multiple occasions, but none addressed bed inspection or entrapment risk. Interviews with the DON confirmed that monthly bed assessments were performed, but these did not include monitoring for entrapment. The Environmental Services Director was unable to provide documentation of bed inspections or entrapment risk assessments, and the facility's Bed/Side-Rail policy did not address these safety concerns. The DON acknowledged that bed assessments for safety were not currently being conducted.