Failure to Complete and Document Bed Rail Entrapment Assessments
Penalty
Summary
The facility failed to complete and document zone entrapment assessments and measurements upon installation of bed rails for three residents who were using bilateral half side rails. For two residents, the required entrapment assessments were not completed or recorded at the time of bed rail installation, as evidenced by the absence of documentation in the facility's Bed Safety Checklist for the relevant months. Observations confirmed that these residents were using the side rails, and interviews with staff indicated that the maintenance department was responsible for installation and assessment, but the necessary documentation was missing. One resident was found to be using bilateral half side rails without a physician's order or a care plan intervention for their use. The maintenance supervisor confirmed that without a physician's order, the entrapment assessment process was not initiated, and no measurements were taken. This was further verified by the absence of documentation in the facility's records and acknowledged by the DON. The facility's policy required that bed frames, mattresses, and bed rails be checked for compatibility and that any gaps in the bed system be within safety dimensions established by the FDA. The policy also mandated routine inspections and proper installation according to manufacturer instructions. However, the lack of completed assessments and documentation for the residents using side rails demonstrated noncompliance with these requirements.