Failure to Assess and Document Alternatives Prior to Bed Rail Use
Penalty
Summary
The facility failed to attempt alternative devices before implementing bed rails for two residents, and did not conduct adequate assessments for risk of entrapment or ensure that bed dimensions were appropriate. Both residents had bed rails or grab bars installed based on their preference, but there was no documentation of alternative methods being tried prior to installation. The assessments did not specify the type of bed rails used, did not include measurements, and did not address the risks of entrapment, particularly in the context of specialty mattresses such as air mattresses. For one resident, the bed mobility device evaluation indicated the use of grab bars, but did not detail the type of rails, measurements, or entrapment risks, nor did it mention the use of an air mattress or any related precautions. The care plan and Minimum Data Set (MDS) did not reflect the use of bed rails or an air mattress, despite the resident having both in use. The resident reported using the rails for repositioning and fall prevention, but was unable to remove them independently. The equipment was provided by hospice, and facility staff were unaware of the specific setup or the associated risks. Staff interviews revealed a lack of awareness and training regarding the safety concerns of bed rails, especially when used with air mattresses. Maintenance staff did not perform zone measurements or physical checks upon implementation, relying instead on verbal assessments and periodic physical checks. Facility leadership believed that the use of grab bars did not require adherence to bed rail regulations or the documentation of alternatives. Manufacturer instructions for the bed, mattress, and rails all emphasized the need for proper assessment, compatibility, and regular inspection to prevent entrapment, but these procedures were not followed. The facility's policy did not address the assessment for restraints, alternative methods, or entrapment risk.