Failure to Assess and Ensure Safe Use of Bed Rail
Penalty
Summary
The facility failed to properly assess and ensure the safe use of a bed rail for a resident with hemiparesis, hemiplegia, transient ischemic attack, major depressive disorder, and chronic pain. The resident, who had mild cognitive impairment and required substantial assistance with mobility, was observed lying in bed with a side rail installed on the right side. The side rail had openings approximately 12.5 inches wide and 18 inches from the top of the rail to the mattress. The resident's medical record did not contain documentation of a side rail assessment or evidence of safe use for the side rail in place. Administrative staff confirmed that bed rails should be assessed quarterly or with significant changes in the resident's status, and acknowledged that the bed rail in use had openings that were too large. The facility's policy requires assessment of the resident for risk of entrapment, review of risks and benefits with the resident or representative, informed consent, and correct installation and maintenance of bed rails, including regular gap measurements following FDA guidelines. These required assessments and safety checks were not documented or performed for the resident in question.