Failure to Assess Bed Entrapment Risk After Mattress Changes
Penalty
Summary
The facility failed to conduct new assessments for bed, side rails, and mattresses in active use for potential entrapment after changing mattresses, as required by facility policy and FDA guidance. This deficiency was identified through observation, record review, and interviews, revealing that two residents with limited mobility and in use of bilateral side rails were at risk for entrapment. Both residents were observed multiple times with air mattresses and side rails in use, and their medical records included physician orders permitting the use of bilateral side rails for turning and repositioning. The facility's policy required adherence to manufacturer instructions and assessment of the space between the mattress and side rails to reduce entrapment risk, but this was not followed after mattress changes. During interviews, the Maintenance Director confirmed that no bed entrapment checks had been conducted since his employment began, and there was no process in place for such assessments. The Administrator provided documentation indicating that all 38 residents in the facility utilized side rails, but no evidence was provided to show that beds were being assessed for entrapment risk. The lack of assessment placed all residents using side rails at risk, as the required safety checks were not performed following mattress changes.