Failure to Assess and Address Bed System Entrapment Hazard
Penalty
Summary
The facility failed to properly assess and address potential accident hazards in a resident's bed system, specifically regarding the risk of entrapment. Observations revealed that a resident's bed had assist bars at the head, a trapeze device, and a significant gap of six to eight inches between the top of the mattress and the headboard, with no footboard present. Further measurement by an LPN confirmed a 10-inch gap between the mattress and the headboard, and the mattress appeared to have slid distally within the bed frame. The facility's prior assessment documentation only addressed gaps between head/foot boards and bed rails, stating they were within FDA limits, but did not evaluate the space between the mattress and the headboard or the stability of the mattress positioning. Interviews with facility leadership confirmed that there was no documentation regarding when the bed system was changed or whether a footboard had been removed. Additionally, the facility was unable to provide evidence of an assessment that considered the risk of mattress sliding and the resulting gap size, which could present a potential entrapment hazard. The deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) for failing to ensure the area was free from accident hazards and that adequate supervision and assessment were provided to prevent accidents.