Failure to Complete Entrapment Assessment Prior to Bed Rail Use
Penalty
Summary
The facility failed to complete an entrapment assessment prior to the application of bed rails for a resident who was at risk for falls and had poor safety awareness. According to the facility's policy, bed rails are considered restraints and require an evaluation for appropriateness, including a side rail assessment, before installation. In this case, after an unwitnessed fall, half side rails were added to the resident's care plan as a fall intervention, but the required entrapment assessment was not initiated until several days later and remained incomplete as of the survey date. The resident was observed in bed with metal half rails in place, and documentation showed cognitive impairment and no prior record of bed rail use on the Minimum Data Set. Interviews with facility staff revealed a lack of awareness regarding the requirement to complete the assessment before applying bed rails. The staff member responsible for medical entrapment assessments confirmed that the process was not started until after the rails were already in use and was never completed. Additionally, the Maintenance Director stated that he only performed quarterly entrapment prevention checklists for residents with existing bed rails and did not conduct new assessments when bed rails were first applied.