Failure to Complete Full Bed Entrapment Assessments for Residents Using Side Rails
Penalty
Summary
The facility failed to ensure that entrapment assessments for bed systems were accurately completed for multiple residents. Specifically, the Bed System Measurement Device Test Results Worksheet used by the facility did not include or document assessments for Zones 6 and 7, which are critical areas identified by the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment. This omission was confirmed through review of facility documentation and interviews with the Maintenance Supervisor, who acknowledged that these zones were not reflected or assessed on the forms for several residents. Observations revealed that numerous residents were found in beds with elevated bilateral side rails, and their medical records showed a range of cognitive and physical impairments, including severe cognitive impairment, fluctuating decision-making capacity, and physical limitations such as osteoporosis and high fall risk. Despite these vulnerabilities, the required entrapment assessments for all seven zones were not completed or documented for these residents. In several cases, staff interviews confirmed a lack of awareness or understanding of the entrapment assessment process, and the documentation consistently showed only Zones 1 to 4 were assessed. The facility's policy and procedure required that bed frames, mattresses, and bed rails be checked for compatibility and entrapment risk, and that maintenance staff routinely inspect all beds and related equipment. However, the actual practice did not align with these requirements, as evidenced by the incomplete assessments and lack of documentation for Zones 6 and 7. This deficiency was identified for nine sampled residents and one non-sampled resident, all of whom had beds with side rails in use, and was verified through direct observation, record review, and staff interviews.