Improper Installation and Maintenance of Bed Positioning Rail
Penalty
Summary
A deficiency was identified when a positioning rail on a resident's bed was found to be loose and improperly positioned, creating a gap of at least 10 inches between the mattress and the rail. This was observed during a survey, with the rail leaning outward at an approximate 120-degree angle. The maintenance supervisor confirmed that the positioning bar was not in the correct position and needed to be fixed. The maintenance log indicated that monthly checks had been documented as completed, but the supervisor admitted that some checks might have been missed, especially if the resident was in bed or the nurse was present. The resident involved had a complex medical history, including Alzheimer's disease, hemiplegia, hemiparesis, aphagia, and a cognitive communication deficit. The resident was assessed as having severe cognitive impairment, daily wandering, and required varying levels of assistance for activities of daily living. The care plan included the use of a positioning bar to assist with transfers and positioning in bed, as well as a fall mat due to frequent attempts to transfer independently. The resident was identified as high risk for falls due to confusion, gait and balance problems, paralysis, poor communication, and sensory deficits. Facility policy required that bed rails be assessed for appropriateness, installed correctly, and regularly inspected for safety, including ensuring no gaps that could lead to entrapment. Despite these policies, the improper installation and maintenance of the positioning rail were directly observed, and the maintenance log did not accurately reflect the actual condition of the equipment. The deficiency was confirmed by both the maintenance supervisor and the administrator during the survey.