Failure to Reassess Bed Rail Use After Significant Change in Condition Resulting in Resident Entrapment and Death
Penalty
Summary
Facility staff failed to reassess the use of bed rails for a resident following a significant change in condition, as required by facility policy. The resident, who had a history of weakness, recent hospitalization for a severe infection, and delirium, was readmitted to the facility with new medical interventions including a PICC line and a closed drain. Despite these changes, there was no documented updated assessment to determine the appropriateness and safety of continued bed rail use after the resident's return from the hospital. The facility's policy required reassessment of bed rail use after significant changes in a resident's status, as well as ongoing monitoring and proper documentation. However, interviews and record reviews revealed that neither nursing nor maintenance staff could provide documentation of a post-hospitalization bed rail assessment. The assistant administrator stated that routine checks were performed but could not confirm if the check occurred before or after the resident's return, nor if the resident was present in the bed at the time. Nursing staff were unclear about the resident's change in status and the requirements for reassessment. The deficiency resulted in a fatal incident where the resident was found entrapped between the bed rail and mattress, unresponsive and later pronounced deceased. Staff interviews confirmed that the resident's head was trapped between the rail and mattress, and that the required reassessment and documentation of bed rail appropriateness following the significant change in condition had not been completed.