Inaccurate Bed Rail Entrapment Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that entrapment assessments for bed rails were accurately and completely performed for two residents who used bilateral grab rails. According to the FDA's guidance, there are seven zones in a bed system where entrapment can occur, and the facility's policy requires regular inspection and assessment of these zones to identify potential risks. However, the entrapment assessments for both residents were incorrectly completed, with some zones marked as 'pass' when they should have been marked as 'not applicable' based on the type of bed rails in use. For one resident, who had moderate cognitive impairment and used bilateral grab rails for mobility and transfers, the assessment marked all seven zones as 'pass' even though only certain zones were relevant for the type of rails installed. Similarly, for another resident who was cognitively intact and also used bilateral grab rails, the assessment again marked all zones as 'pass' instead of correctly identifying which zones applied. The maintenance supervisor, responsible for these assessments, was found to have used an incorrect method for measuring one of the zones and confirmed that the assessments were inaccurate. Observations and interviews with staff, including the Director of Nursing and the maintenance supervisor, verified that the entrapment assessments were not completed according to the facility's policy or the FDA guidance. The inaccurate assessments had the potential to negatively impact residents by failing to properly identify and mitigate entrapment risks associated with the use of bed rails.