Failure to Conduct Regular and Documented Bed Rail Safety Inspections
Penalty
Summary
The facility failed to conduct regular and thorough inspections of bed frames, mattresses, and bed rails as part of its maintenance program, specifically for two residents who were using bed rails. Both residents were cognitively intact and required varying levels of assistance with activities of daily living. Observations revealed that one resident was using an air mattress and bilateral halo bed rails, while another was using bilateral quarter rails at the head of the bed. In both cases, the use of bed rails was not documented in the Minimum Data Set (MDS), and there was no evidence that compatibility or entrapment risks were assessed upon implementation. Interviews with facility staff, including the director of maintenance, LPN, ADON, DON, and the administrator, revealed a lack of clarity and consistency regarding the inspection process for beds and bed rails. The director of maintenance admitted to not being aware of specific bed rail installations, such as the halo rail with an air mattress, and had not performed physical checks on beds with electric features or bed rails. The maintenance checks were inconsistently documented, often relying on verbal confirmation from nursing staff or a general check mark in the TELS system, rather than detailed, resident-specific documentation. There was also uncertainty about who was responsible for verifying the compatibility of beds, mattresses, and rails, especially for equipment provided by hospice. Manufacturer instructions for the air mattress, halo rails, and quarter bed rails all emphasized the importance of regular inspections, ensuring compatibility, and minimizing gaps to prevent entrapment. However, the facility's maintenance documentation did not specify the frequency of inspections, criteria for identifying entrapment zones, or procedures for verifying equipment compatibility. The facility's policy on safe medical devices did not address inspection or maintenance requirements for these devices, contributing to the deficiency in ensuring resident safety related to bed systems.