Failure to Assess and Mitigate Bed Rail Entrapment Risks Results in Resident Death and Immediate Jeopardy
Penalty
Summary
The facility failed to thoroughly assess residents for the risk of entrapment when utilizing bed rails, particularly when used in combination with alternating pressure mattresses (APMs). The assessment process did not include compressing the APM to measure the potential gap between the mattress and the side rail, nor did it address the medical needs to be met by bed rail use, the risks associated with bed rails and how these would be mitigated, or alternatives that were attempted or considered. Documentation was lacking regarding any attempts to use alternatives prior to installing side rails for multiple residents. The Siderail Safety Questionnaire used by the facility did not capture these critical elements, and there was no evidence in the medical records that these assessments or considerations were made for the residents reviewed. One resident, who was severely cognitively impaired, dependent on staff for activities of daily living, and required a mechanical lift for transfers, was found deceased with his head wedged between the APM and the right-side grab bar rail, and his lower body on the floor mat next to the bed. The coroner determined the cause of death to be asphyxia due to neck compression from being wedged between the safety rail and mattress. Observations of the bed after the incident revealed significant gaps between the compressed APM and the side rail, which were not accounted for in the facility's assessment process. The facility's practice was to measure gaps only when the resident was lying on the bed, not when the bed was unoccupied or when the mattress was compressed, leading to unrecognized hazards. Additional residents were also found to be at risk due to similar failures in assessment and documentation. For each of these residents, there was no evidence that alternatives to side rails were attempted or considered, and the Siderail Safety Questionnaire did not include required information about medical needs, risk mitigation, or alternative interventions. Observations and interviews confirmed that gaps between the APM and side rails exceeded safe limits when the mattress was compressed, and staff were unaware of the need to assess these conditions. These deficiencies resulted in Immediate Jeopardy and serious harm, including death for one resident, and placed others at risk for entrapment.