Failure to Secure Bed Rails and Maintain Inspection Documentation
Penalty
Summary
The facility failed to ensure that bed rails were securely affixed to the bed frame, resulting in loose rails that created a gap of approximately 4-5 inches between the mattress and the rail for one resident. During observations on multiple dates, the bed rails were found to be unstable and easily tilted away from the mattress. The facility was unable to provide current bed rail inspection logs when requested, only producing a single audit from the previous year and indicating that audits were conducted annually. Despite being informed of the issue, the loose bed rails were not addressed for several days until surveyor intervention. The Maintenance Director confirmed the rails were loose during a joint observation with the surveyor, acknowledging that he had previously attempted to tighten them, but the problem persisted.