Failure to Assess Entrapment Risk and Attempt Alternatives Prior to Side Rail Use
Penalty
Summary
The facility failed to assess entrapment risk and attempt alternatives prior to the use of side rails (u-shaped grab bars) for two residents. Both residents were admitted with significant medical conditions, including hypertensive heart disease, chronic kidney disease, and heart failure. Documentation in their electronic medical records showed that bed rail assessments were completed, indicating the use of bilateral u-shaped grab bars as enablers to promote independence, and both residents expressed a desire to have them. However, the assessments did not include any evaluation of entrapment risk or documentation of alternative interventions attempted before the installation of the grab bars. Care plans for both residents did not reference the use of u-shaped grab bars, despite their ongoing use. Minimum Data Set (MDS) assessments indicated that one resident was dependent on staff for bed mobility and non-ambulatory, while the other was independent with bed mobility and transfers but had impairments in both lower extremities and one upper extremity. Observations confirmed that both residents were using the u-shaped grab bars in the raised position, and interviews with the residents confirmed their use for positioning and mobility assistance. Interviews with facility staff, including the DON, MDS Nurse, Administrator, and Rehabilitation Manager, revealed a lack of awareness regarding the requirement to conduct entrapment risk assessments and to attempt and document alternatives before implementing side rails. Staff believed that therapy or nursing assessments covered these requirements, but therapy staff clarified that they did not perform entrapment risk evaluations. The facility used a corporate-provided side rail assessment tool, but it did not prompt for entrapment risk evaluation or alternative interventions.