Failure to Complete Bed Rail Safety Assessment Prior to Use
Penalty
Summary
The facility failed to complete a required safety assessment prior to the use of bed enabler bars for one resident. According to the facility's bed safety policy, the interdisciplinary team is responsible for assessing the resident's sleeping environment, including safety, medical conditions, comfort, and freedom of movement, as well as obtaining input from the resident and family. The policy also requires regular inspection of beds and related equipment to identify risks, including potential entrapment hazards. For a resident with moderate cognitive impairment, a history of falls, and a diagnosis of dementia, physician orders directed the use of bilateral enabler bars. Observations confirmed that these bars were in place, but there was no documented evidence that a safety assessment had been completed prior to their application. The DON confirmed that the required assessment was not performed for this resident.