Failure to Address Side Rail Padding Risks Through QAPI
Penalty
Summary
The facility failed to ensure that the Quality Assurance Performance Improvement (QAPI) committee developed and implemented appropriate plans of action to address issues related to side rail padding for four of twenty-seven residents reviewed. Specifically, the facility did not assess residents for risk of entrapment from bed rails prior to installation and did not ensure that the bedrails did not pose a risk of entrapment, asphyxiation, suffocation, or injury. Observations revealed that blankets and pillows were attached with tape to the side rails in place of proper side rail pads for these residents, increasing the likelihood of entrapment. Interviews with facility leadership, including the Director of Nursing Services and the Administrator, confirmed awareness of the practice of using blankets and pillows as padding and indicated that this practice was considered acceptable by the facility. The issue had not been discussed or addressed in any QAPI committee meetings, and there was no evidence that the committee had reviewed, analyzed, or acted on available data regarding the identified concern.