F0909

F

Failure to Inspect and Document Safety of Beds and Bed Rails per MIFU and FDA Guidance

Milwaukee, Wisconsin Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to conduct and document required inspections and safety assessments of resident beds, including bed frames, mattresses, and bed rails or assist/mobility bars. Surveyors observed resident beds with assist/mobility bars in use. During interviews, the Nursing Home Administrator stated there were no bed inspections being conducted and confirmed there was no policy regarding bed inspections. The Maintenance Director reported that when a new admission is anticipated, maintenance staff go to the room, remove safety bars, ensure a mattress is present, inspect the bed, test the remote, and check for exposed wires, and that therapy may later order safety bars or bed extensions or special mattresses. However, the Maintenance Director acknowledged that these inspections are not documented.

Review of the Manufacturer’s Instructions for Use (MIFU) for Joerns Model U770, U790, and U795 beds showed that the beds and accessories are to be visually inspected monthly for broken welds, cracks, and loose hardware, and that any bed with such defects must be removed from service and repaired. The facility did not document that these monthly inspections were performed for any of the 77 resident beds. In addition, review of FDA guidance on hospital bed system entrapment risks identified seven potential entrapment zones and recommended dimensional limits for zones 1–4. The Maintenance Director stated that although they have reference sheets describing the seven or eight entrapment zones and related measurements, the facility does not perform or document FDA entrapment safety zone measurements for any of the 36 residents identified as having bed rails, mobility bars, or assist bars.