F0909

D

Failure to Assess, Order, Document, and Inspect Bed Rail Use

New Castle, Delaware Survey Completed on 12-13-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to assess, obtain orders for, and accurately document the use of bed rails for a resident, as well as failure to inspect bed rails at installation and routinely thereafter as required by facility policy. The resident, admitted with diagnoses including anoxic brain damage and persistent vegetative state, was totally dependent on staff for all ADLs, including bed mobility and transfers, and was unable to communicate or move her body. On multiple observations over several days, grab bars/bed rails were found raised on both sides of the resident’s bed while she lay in a vegetative state and unable to move. During a joint observation with an LPN, it was confirmed that bed rails were in the raised position on both sides of the bed.

Review of the resident’s admission MDS showed that a BIMS was not completed due to poor cognition and inability to communicate, and the assessment indicated the resident did not have bed rails in place. The physician’s orders contained no orders for bed rail use, and facility documentation showed no assessment had been conducted prior to installation of the bed rails. The Maintenance Director stated that while beds were routinely inspected for overall safety, rails applied to residents’ beds were not inspected at the time of installation or routinely thereafter. The Regional Director of Operations confirmed that bed and rail safety assessments were expected when rails were initiated and then routinely thereafter. The facility’s Bed Rail Policy required evaluation of risks prior to installation using a Bed Rail Safety Checklist, ensuring appropriate bed dimensions, correct installation per manufacturer’s recommendations, correct use, and scheduled maintenance, but these steps were not documented or carried out for this resident’s bed rails.