Failure to Inspect Bed Rails After Reinstallation
Penalty
Summary
The facility failed to conduct regular inspections of bed rails/enabler bars as part of its maintenance program to identify possible areas of entrapment for a resident with hemiplegia. The resident had a physician order for a right-side enabler bar to assist with bed mobility and independence, and the enabler bar assessment and consent were completed when the device was initially placed. However, the maintenance record for safety measurements was last documented several months prior to the most recent placement of the enabler bar. When the enabler bar was removed at the resident's request and later reinstalled, the facility did not perform or document the required safety measurements at the time of reinstallation. Interviews with facility leadership confirmed that safety measurements should have been completed when the enabler bar was placed back on the bed, but this was not done, resulting in noncompliance with regulatory requirements for regular inspection and compatibility checks of bed rails and related equipment.
Plan Of Correction
1. R 14's bed was inspected by maintenance, and no area of entrapment was identified. 2. An audit was conducted throughout the skilled unit on 12/11/25 to identify current residents that have beds with rails. A Maintenance Bed evaluation and inspection was completed on the identified beds on 12/11/25 with no concerns noted. 3. Environmental Services will be re-educated by the Executive Director on the facility preventative maintenance program to include regular inspection of bed rails/enabler bars, and completion of the Bed Evaluation Tool. Education will include any device being added to the bed or frame requires inspection and completion of the Bed Evaluation Tool immediately upon adding to the bed or frame by maintenance. 4. Weekly audits x 12 weeks of residents with bedrails will be completed by the Director of Nursing or designee to validate current bed rail inspection is documented at least annually at the time of placing rails or enablers on bed if newly added, and when a significant change of condition occurs. Findings of audits will be analyzed to identify/track trends or patterns and will be reported to the facility Quality Assurance/Performance Improvement Committee for review and/or recommendation.