Failure to Routinely Inspect Resident Beds for Entrapment Risk
Penalty
Summary
The facility failed to ensure that all resident bed frames, mattresses, and bed rails were routinely inspected for safety and entrapment risk on all three units. Interviews with the Director of Maintenance (DOM) and the Administrator revealed that there was no current policy or systematic process in place to guarantee annual inspections of resident beds. Although the DOM stated that beds should be inspected yearly using an entrapment risk tool, documentation in the Bed Assessment book showed that only a portion of beds were inspected over the past year, with no evidence that all beds received annual assessments as required. Record review indicated that out of 132 beds, only 25 were inspected in December, 59 between April and November, and 4 in late November, leaving a significant number of beds without documented annual inspection. Both the DOM and the Administrator confirmed the absence of a formal policy and a reliable system to ensure timely and routine bed inspections. No information was provided regarding specific residents affected or their medical conditions at the time of the deficiency.