Failure to Perform Required Bed Rail Safety Assessments and Maintenance
Penalty
Summary
The deficiency involves the facility’s failure to follow its own bed safety and bed rail policy and the resident’s care plan requirements for assessment and monitoring of bed rails. The facility was required to assess residents for safety risks related to bed rails, review risks and benefits with the resident or representative, obtain informed consent, and ensure proper installation and maintenance of bed rails. For one resident, the facility did not complete the required quarterly bed rail safety assessments as outlined in the comprehensive care plan, which specified that nurses would review bed rails quarterly to minimize risks and ensure the device was least restrictive. The resident involved was an adult female with diagnoses including hypertensive heart disease, obesity, and muscle wasting and atrophy. Her Quarterly MDS showed intact cognition with a BIMS score of 15/15, no functional limitation in range of motion of upper and lower extremities, and dependence on staff for chair-to-bed and toilet transfers, requiring mechanical transfers with two persons. The care plan and physician orders documented the use of bilateral one-quarter bed rails to promote independence with bed mobility and positioning, and a bed rail assessment completed in May 2025 indicated that side rails/assist bars were appropriate and served as an enabler to promote independence. However, there were no subsequent bed rail assessments completed for the second and third quarters of 2025. During observation, surveyors noted that the resident’s bed had bilateral one-quarter bed rails in the up position, and a CNA was unable to lower either rail because they were jammed. The CNA and an LVN both stated they were unaware that the bed rails could not be lowered and reported that the resident had not complained about the rails. The DON acknowledged that the bed rails should have been able to be lowered without difficulty for safety, confirmed that quarterly bed rail assessments were not completed as required, and stated that because these assessments were not done, the facility did not know the bed rails were not functioning correctly. The facility’s written policy required that bed rails be properly installed and used according to manufacturer’s instructions and that residents be evaluated for bed rail use if alternatives did not meet their needs, but these processes were not carried out as required for this resident.
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