Failure to Assess Entrapment Risk Prior to Bed Rail Installation
Penalty
Summary
The facility failed to assess a resident with cognitive deficits for the risk of entrapment prior to the installation of bed rails. The resident in question had diagnoses including unspecified dementia with behavioral disturbances, depression, bipolar disorder, and other cognitive and behavioral symptoms. The resident was moderately impaired in cognition, required supervision or assistance for bed mobility, and was noted to be impulsive with poor safety awareness. Despite these factors, bed rails were installed without a documented risk assessment for entrapment, as required by facility policy. Staff interviews revealed that the bed rails were used to assist with bed mobility and as a fall risk intervention, but there was no separate risk assessment form completed prior to their use. The consent form signed by the resident's Power of Attorney was incorrectly considered as the risk assessment by staff. Observations showed the resident in bed with half side rails raised on both sides, and staff confirmed that the resident could exit the bed by sliding to the foot of the bed. The resident's care plans documented cognitive impairment, confusion, and poor decision-making abilities, yet the facility did not perform or document a specific entrapment risk assessment before installing the bed rails. The facility's policy required such an assessment, but staff acknowledged that this step was not completed, and the required documentation was not present in the resident's records.