Failure to Prevent Bed Entrapment Hazards and Ensure Resident Safety
Penalty
Summary
Surveyors observed that several resident beds in the facility had excessive gaps, specifically at the foot of the beds, with no gap fillers in place. These gaps were greater than approximately 5 inches and were identified as potential entrapment hazards for multiple residents. During the inspection, one resident was found with his arm entrapped between the mattress and side rail, confirming the risk posed by these gaps. The maintenance assistant verified the presence of these hazards during an interview. One resident, who had severe cognitive impairment and a history of falls, experienced a significant injury as a result of these hazards. This resident was found on the floor with his left arm stuck between the bed and bed rail, resulting in an arterial tear that required surgical intervention. Witness statements indicated that the bed was at an unusually high position, both bed rails were up, and the resident's call light and bed remote were on the floor. The resident was unable to squeeze with his left hand after the incident, and a knot was observed in his left armpit. A review of the resident's bed safety evaluation revealed that critical steps, including risk factor evaluation and checking for zones of entrapment, were not completed or documented. The lack of proper assessment and failure to address the identified hazards led to the entrapment and injury. The survey team confirmed that, at the time of their investigation, no further potential entrapment areas were observed between mattresses and side rails.