Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to assess and obtain consent before bed rail use for two residents. Two cognitively intact residents with diagnoses including AFib, HTN, arthritis, CAD, and HF were observed with bed rails on their beds even though their MDSs indicated no bedrail use. Both records lacked a bedrail assessment, consent, and education, and the DON confirmed no assessment had been completed before the rails were installed.
A resident with severe cognitive impairment and total dependence for care fell from bed after an air mattress was set too high for the resident’s weight, causing the mattress to overinflate and push the resident into a siderail. The resident’s arm became trapped in the rail and the resident sustained neck and sternum injuries. The record also showed no siderail entrapment assessment for the resident, and multiple other residents with air mattresses and siderails also lacked documented side rail assessments.
A facility failed to complete ongoing reassessments of bed siderail safety for a resident with severe cognitive impairment and total dependence for bed mobility. The resident continued using the siderails for months without the required review, and later developed bruising and a traumatic posterior shoulder dislocation after the arm was reportedly caught in the rail. An internal investigation and later assessment found the siderails were unsafe and no longer indicated.
Failure to Assess and Obtain Consent for Bed Rail Use: Two residents had one-quarter bed rails in place with physician orders for positioning and mobility, but the clinical record lacked documented bed rail safety assessments and signed informed consent. One resident had moderately impaired cognition and the other had severely impaired cognition; both were observed with the rails up and locked in place. The ADM and DON acknowledged the assessments and consents were missed, and staff stated the required documentation should have been completed before bed rail use.
A resident with acute and chronic respiratory failure with hypoxia, Type 2 DM with hyperglycemia, generalized muscle weakness, and impaired cognition was placed in four locked bed rails for fall risk. The record showed only one alternative intervention, one-to-one activities and supervision, with no documented evidence explaining why it was ineffective, and the DON stated there was no documented active order for a low bed or other alternative. The resident was observed asleep with all four bed rails up and locked, and the care plan and active orders did not show monitoring for safe bed rail use.
Failure to Assess Bed Rail Entrapment Risk: A resident with severe cognitive impairment and multiple medical conditions was placed in a bed with assist rails without documented assessment for appropriateness, documented alternatives, or informed consent. Staff later found the resident with his head and neck trapped between the mattress and the assist bar, unresponsive and not breathing, and CPR was started before EMS transported him to the hospital. The resident was admitted with cardiac arrest and diffuse hypoxic injury and later expired.
Failure to Assess and Obtain Consent Before Bed Rail Use
Penalty
Summary
The facility failed to comprehensively assess and attempt alternatives before using bed rails for 2 of 6 residents reviewed for bed rail use. R55’s MDS indicated she was cognitively intact and had diagnoses including atrial fibrillation, high blood pressure, and arthritis. Although Section P of the MDS indicated R55 did not use bedrails, during observation on 7/6/26 her bed had half-length bed rails attached to both sides. R55 stated the rails had been there since admission and that she did not routinely use them. Her medical record lacked an assessment, consent, and education for bedrail use. R16’s quarterly MDS indicated he was cognitively intact and had diagnoses including coronary artery disease, heart failure, and high blood pressure. Section P of the MDS indicated R16 did not use bedrails, but during observation on 7/6/26 his bed had quarter bed rails attached to both sides. R16 stated he did not use them and could not recall how long they had been on his bed. His medical record also lacked an assessment, consent, and education for bedrail use. The DON stated a resident using bedrails required an assessment for appropriateness, a physician’s order, consent, and education, and confirmed R55 and R16 had not had a bedrail assessment prior to installation.
Failure to Assess Bed Rail Entrapment Risk and Mattress Settings
Penalty
Summary
The facility failed to assess residents for risk of entrapment from bed siderails and failed to calibrate an alternating air flow mattress setting for a resident’s weight. The report states that these failures resulted in one resident’s mattress becoming overinflated, which caused the resident to fall into the bedrail and to the floor. During the fall, the resident’s arm became entrapped in the bedrail and the resident was unable to reposition the head and neck away from the rail, resulting in neck and sternum injuries. The affected resident had diagnoses including unspecified dementia with agitation, osteoarthritis, osteoporosis with a history of left femur fracture, generalized muscle weakness, unsteadiness on feet, need for assistance, and abnormalities of gait and mobility. The resident’s MDS documented severe cognitive impairment and total dependence on staff for all ADLs, including bed mobility and transfers. The resident’s care plan included use of a low-air-loss mattress, but the record did not contain a side rail assessment to determine risk for entrapment or safety before siderails were used. After the fall, the resident was found sitting on the floor with the face and arm by the side rail, with bruising and abrasions/tears to the neck and bruising to the neck and sternum area. The fall investigation documented that the resident slid off the side of the bed and that the low air loss mattress appeared to be set for a much heavier weight than the resident’s actual weight. The investigation did not identify side rail involvement as part of the root cause or include an intervention related to the siderail. The report also states that 10 additional residents reviewed for side rails and accidents had no side rail assessments in their records, and all had air mattresses and bed siderails in place.
Failure to Reassess Bed Siderail Safety Led to Resident Injury
Penalty
Summary
The facility failed to ensure the correct use and ongoing reassessment of bed siderails for one resident who had severely impaired cognition and was totally dependent on staff for bed mobility. The resident was admitted with diagnoses including Alzheimer's disease and polyosteoarthritis, and a Quarterly MDS assessment showed a BIMS score of 4 out of 15, indicating severely impaired cognition. The record showed that the resident continued to use bed siderails, but the facility did not document the required reassessments of the continued need for and safety of the siderails for approximately 15 months after the last reassessment. After the resident was found with bruising to the right armpit and right posterior arm, the resident was transferred to the Emergency Department and diagnosed with a closed traumatic posterior dislocation of the right shoulder. Because of the resident's cognitive impairment, the resident could not recall how the injuries occurred. In the facility's internal investigation, the former DNS stated that the bruise appeared shaped like the side rail, with striations matching the bars on the rail, and that the resident slept on the right side with the arm around the side rail. The statement indicated the arm likely became caught in the siderail and the shoulder was dislocated when the resident tried to pull it out. The facility's records did not show evidence that the required ongoing reassessments were completed after 2/4/2025 to determine whether the bed siderails remained clinically appropriate and safe. During surveyor interview, the Administrator, with the current DNS present, was unable to provide evidence of the required reassessments. A bed siderail assessment completed after the injury determined that the siderails were unsafe for the resident's continued use and were not indicated because they created an accident hazard.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to assess two residents for the risk of entrapment from bed rails before the rails were installed and failed to document informed consent for their use. Resident #38 had diagnoses including unspecified dementia, unspecified fall, subsequent encounter, and major depressive disorder. Her quarterly MDS showed a BIMS score of 11, indicating moderately impaired cognition, and Section GG showed she was independent with sit-to-lying and sit-to-stand. Her care plan identified a one-quarter bed rail for mobility, and physician orders dated 06/09/2026 authorized the rail for positioning and mobility, but the clinical record contained no signed bed rail consent and no current bed rail safety assessment prior to installation. During observation, she was seen in her room with the one-quarter bed rail up and locked in place. Resident #89 had diagnoses including senile degeneration of the brain, major depressive disorder, and history of falling. Her quarterly MDS showed a BIMS score of 03, indicating severely impaired cognition, and Section GG showed she required supervision or touching assistance with sit-to-stand and chair-to-bed transfer. Her care plan identified a one-quarter bed rail for mobility and positioning, and physician orders dated 06/01/2026 authorized the rail for positioning and mobility, but the clinical record contained no signed bed rail consent and no current bed rail safety assessment prior to installation. During observations, she was seen lying in bed asleep with the one-quarter bed rail up and locked in place. During interviews, the ADM stated she and the DON had recently audited bed rail assessments and consents, but Residents #38 and #89 had been missed. The DON stated the missed assessments were her responsibility and that bed rail assessments and consents were required before implementation and reviewed quarterly. Facility staff also stated that completion of bed rail assessments and consents was the responsibility of the charge nurse, and the facility policy required review of alternatives, assessment of entrapment risk, and informed consent before bed rail use.
Failure to Document Alternatives and Monitor Bed Rail Use
Penalty
Summary
The facility failed to evaluate why alternative interventions were ineffective before installing four bed rails for Resident 10 and failed to monitor the resident’s use of side rails as required by the facility’s Bed Safety and Bed Rails policy. Resident 10 was admitted with acute and chronic respiratory failure with hypoxia, Type 2 DM with hyperglycemia, and generalized muscle weakness. The record showed that the only alternative intervention documented before bed rail use was one-to-one activities and supervision, but there was no documented evidence explaining why that alternative did not work. An order dated 3/30/2026 indicated bilateral full bed rails due to fall risk, and the care plan later documented all bed rails up and locked when in bed with an intervention to attempt less restrictive devices on an ongoing basis. Resident 10’s history and physical stated the resident did not have capacity to understand and make decisions, and the MDS described moderately impaired cognition, dependence for ADLs and functional mobility, no prior falls in the 2 to 6 months before admission, and daily use of bed rails. During observation, Resident 10 was found asleep in bed with all four bed rails up and locked. The DON stated there was no documented evidence of an active order for a low bed and no other alternative attempted with a documented reason for its inability to meet Resident 10’s needs before placing four bed rails. The DON also stated the care plan did not indicate monitoring for bed rails while in use and the Active Orders list did not show an active order to monitor the safe use of the bed rails.
Failure to Assess Bed Rail Entrapment Risk
Penalty
Summary
The facility failed to thoroughly assess residents for the risk of entrapment and the appropriateness of using bed rails. The deficiency involved Resident #11, who was admitted with diagnoses including a right hip fracture, anxiety disorder, orthostatic hypotension, depression, and Alzheimer’s disease. The resident’s MDS showed severe cognitive deficits and dependence on staff for activities of daily living, including rolling in bed. The record contained no documentation that the resident was assessed for the use of side rails, and there were no documented alternatives attempted before the resident was placed in a bed equipped with bed rails. On 05/23/26, staff found Resident #11 in distress in his room with his head and neck caught between the mattress and the assist bar, and his lower jaw stuck inside the handle of the assist bar. CNA #138 and RN #50 removed the mattress from the opposite side of the bed to free the resident and lower him to the floor. The resident was not breathing and was non-responsive, and RN #50 initiated CPR until EMS arrived and took over rescue efforts. EMS later reported the resident had a pulse and transported him to the hospital. Witness statements and the EMS run sheet described the resident as being found with his head stuck between the bed railing and the bed, with signs of obstruction to breathing. The hospital record stated the resident was admitted after being found down between the bed and an assist rail with cardiac arrest and diffuse hypoxic injury. He was intubated, mechanically ventilated, later transitioned to comfort-focused care, and expired on 06/01/26. The facility policy required attempts at alternatives, interdisciplinary evaluation, resident assessment, and informed consent before use of bed rails, and the report states these steps were not completed for Resident #11.
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