Failure to Maintain Bed Systems and Prevent Entrapment Hazards
Penalty
Summary
The facility failed to maintain an effective inspection and maintenance program for bed frames with bed extenders, resulting in unaddressed entrapment hazards in multiple resident rooms. Specifically, observations revealed that two residents were using bed frames with extenders that created significant gaps—ranging from approximately 4 to 6 inches—between the mattress and the footboard. In one instance, the gap was filled with wedges typically used for repositioning, rather than equipment designed to eliminate entrapment zones. Additional rooms were also found to have similar gaps when bed extenders were in use. Interviews with facility staff, including the physical therapy director, confirmed that the practice was to use repositioning wedges to fill these gaps when bed extenders were applied. This practice was acknowledged during the survey, and the information was reviewed with the Nursing Home Administrator. The deficiency was identified for two residents out of a sample of 29, as well as in three observed resident rooms, indicating a lack of consistent and appropriate maintenance procedures to minimize or eliminate entrapment hazards as required.