Failure to Assess and Address Bed Entrapment Risk
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards by not assessing and addressing the risk of entrapment for one resident. The resident, who had diagnoses including acute diastolic heart failure, muscle weakness, and cognitive communication deficit, was observed on two consecutive days with their bed positioned so that the right side was pushed up against an air conditioning unit, leaving a gap of approximately six to eight inches between the mattress and the window and wall. The headboard was also positioned about two feet away from the wall. These observations were confirmed by staff interviews, with the Registered Nurse unable to confirm if an entrapment risk assessment had been completed for the resident. A review of the clinical record revealed that there was no assessment to determine the resident's risk for entrapment. The Director of Nursing confirmed that the bed's position created a potential danger and that the resident had not been assessed for entrapment risk. Facility policy indicated that the environment should be free from accident hazards and that supervision and assistive devices should be provided to prevent avoidable accidents, but this was not followed in this instance.