Failure to Assess for Entrapment Risk Prior to Bed Rail Use
Penalty
Summary
The facility failed to assess a resident for risk of entrapment prior to the installation and use of bed rails. A resident with a history of hemiplegia, hemiparesis, left knee contracture, and chronic pain was observed using quarter bed rails in the upright position on both sides of her bed. The resident reported using the bed rails to reposition herself while in bed. Review of the resident's electronic medical record revealed no documentation of an assessment for entrapment risk before the bed rails were installed or used. Interviews with staff indicated that bed rail assessments were typically completed when therapy recommended bed rails for independent bed mobility, and reassessments were conducted quarterly. However, the DON stated that an assessment was not completed in this case because the bed rails were ordered by Hospice. The Administrator confirmed that bed rail assessments were expected to be completed according to facility policy, but this was not done for the resident in question.