Failure to Assess Entrapment Risk Prior to Bed Rail Installation
Penalty
Summary
The facility failed to ensure that residents were assessed for the risk of entrapment prior to the installation of bed rails for two out of three residents identified as having side rails in use. According to the facility's own policy, an assessment should be conducted to determine the resident's symptoms, risk of entrapment, and the reason for using side rails. For both residents involved, there was no documented evidence that such an assessment was completed before bed rails were installed. One resident had multiple diagnoses, including acute and chronic respiratory failure, heart failure, COPD, dementia, and metabolic encephalopathy, and was observed with bilateral quarter rails in the up position. The resident's care plan and physician's orders indicated the use of assist rails as an enabler, but the medical record lacked documentation of an entrapment risk assessment. Another resident, with diagnoses including atrial fibrillation, muscle weakness, unsteadiness, dementia, and major depressive disorder, was also observed with quarter bed rails in use. Similarly, the record for this resident did not contain evidence of an entrapment risk assessment prior to bed rail installation. Interviews with facility administration confirmed the absence of required documentation for both residents.