Failure to Ensure Bed Rail and Bed Frame Compatibility
Penalty
Summary
The facility failed to ensure that a separately purchased bed rail and bed frame were compatible for a resident who was reviewed for bed rail use. The resident, who had moderate cognitive impairment and a diagnosis of schizophrenia, used a grab bar on the bed to assist with independent bed mobility and transfer. During observation, the bed rail was found to be loose, moving back and forth and sliding up and down in its sleeve. The resident confirmed that the rail always moved and demonstrated its instability. Staff interviews revealed that the bed rail could not be tightened further and that the rail was not made for the bed in use. The Environmental Service Director acknowledged that some beds and rails were old, and there was no way to determine compatibility due to missing manufacturer information. The facility's policy required that bed rails be installed per manufacturer guidelines and that compatibility be ensured. However, the staff were unable to provide manufacturer recommendations for the bed rail and bed frame, and the Environmental Service Director admitted to using extra screws in an attempt to secure the rail. The Administrator confirmed that only universal rails were ordered for use with various beds, but acknowledged the loose rail as a safety risk. The facility's failure to ensure compatibility and proper installation of the bed rail and bed frame resulted in a deficiency related to resident safety.