Failure to Assess Bed Rail Entrapment Risk Prior to Installation
Penalty
Summary
A deficiency was identified when a resident, who was cognitively impaired and required staff assistance for daily care needs, was provided with bilateral bed enabler bars as per physician's orders. The resident's clinical records and observations confirmed the presence of these enabler bars on the bed. However, there was no documented evidence that an assessment for potential safety hazards or risk of entrapment from the bed rails was completed prior to their installation. This was confirmed during an interview with the Director of Nursing, who acknowledged that a bed rail/enabler safety assessment had not been performed for the resident.
Plan Of Correction
Resident R36 was evaluated by the Occupational Therapist to ensure that bilateral bed-enabler bars were the most appropriate. An "In bed positioning/siderail evaluation" was completed on resident R36. The Director of Nursing or designee is completing a review of all residents currently utilizing enabler bars to ensure that an up-to-date assessment is complete. Nursing staff will be provided education on the process for utilization of enabler bars on resident beds and proper completion of quarterly assessments. The Director of Nursing or designee will complete audits for completion weekly x4, then biweekly x4, then monthly x2, with results to the Quality Assurance Committee.