Failure to Assess Bed Rail and Mattress Safety After Changes
Penalty
Summary
The facility failed to conduct required safety inspections and assessments of bed rails and mattresses for three residents, resulting in unaddressed risks of entrapment. Specifically, two residents with limited mobility who utilized bilateral side rails received new air mattresses, but the facility did not complete new assessments of the bed, side rails, and mattresses for potential entrapment after the mattress changes. Documentation did not show that these beds had ever been measured for entrapment risk following the changes, despite the residents' ongoing use of side rails and pressure-reducing devices. For another resident, the facility did not ensure that a mattress bolster or extender was in place to fill a significant gap between the mattress and the footboard, leaving the metal bed frame exposed. Multiple observations confirmed a gap of approximately six inches at the foot of the bed, with no filler piece installed, despite the resident's continued use of the bed. The last documented assessment for this resident was outdated and did not reflect the current mattress in use. Interviews with facility staff revealed a lack of awareness regarding the requirement for regular side rail safety assessments, particularly when mattresses are changed. The maintenance director was unaware of the need for these assessments, and the regional maintenance director acknowledged that inspections should have been conducted after mattress changes. The documentation provided by the facility was incomplete and did not include the necessary assessments for the affected residents.