Failure to Conduct Regular Bed Inspections and Entrapment Assessments
Penalty
Summary
The facility failed to conduct regular bed inspections as part of its maintenance program to identify potential areas of entrapment for two residents. According to facility policy, maintenance staff are required to inspect all beds and related equipment, including bed frames, mattresses, and side rails, to identify risks such as entrapment. However, interviews with the Maintenance Supervisor revealed that monthly bed inspections were performed visually without documentation, and no entrapment assessments were conducted. The Maintenance Supervisor also stated that he did not have the necessary measuring device to assess entrapment zones and had not received or requested such a tool. For one resident, who was cognitively intact and used bilateral grab bars for bed mobility and repositioning, there was no documented evidence of an entrapment assessment being completed. The resident's medical record included a physician's order for the use of grab rails, but neither the maintenance staff nor nursing staff performed or documented the required entrapment assessment. The ADON confirmed that while an assessment related to the use of the device was completed, a specific entrapment assessment was not performed. Another resident, who had fluctuating mental clarity due to multiple comorbidities and medications and required extensive assistance for mobility, also used bilateral halo rails. Despite a physician's order and staff interviews confirming the use of these rails for mobility and repositioning, there was no evidence of a regular bed inspection or entrapment assessment. Staff interviews indicated a lack of awareness and training regarding the need for entrapment assessments, and no documentation or logs of such assessments were available.