Failure to Assess and Prevent Bed Rail Entrapment Risk
Penalty
Summary
The facility failed to assess residents for the risk of entrapment from bed rails prior to their installation and did not ensure that the bed rails did not pose a risk of entrapment, asphyxiation, suffocation, or injury. This deficiency was identified for four residents, all of whom had diagnoses such as seizure disorder, muscle wasting and atrophy, cerebral palsy, dementia, and asthma. Observations revealed that these residents had blankets and pillows taped to their side rails in place of proper side rail pads, a practice that was acknowledged and accepted by the facility's Administrator. There was no documented evidence in the medical records that these residents were assessed for entrapment risk before the installation of the side rails, nor that they or their representatives were educated about the risks and benefits or provided consent for the use of the side rails. Physician orders for seizure precautions specified the use of bilateral padded quarter side rails, but in practice, the facility substituted blankets and pillows for proper padding. Multiple observations confirmed the ongoing use of these makeshift pads, and interviews with the Administrator confirmed awareness and acceptance of this practice. The lack of proper assessment, documentation, and use of appropriate equipment directly contributed to the deficiency, with the potential to affect all residents in the facility.