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:
Inaccurate bedrail care plans and missing ongoing assessments were identified for three residents. Two residents had bilateral enabler bars observed on their beds, but their last enabler-restraint assessments were outdated, and one resident had bilateral enabler bars with no order or ongoing assessment in the record. The residents had diagnoses including HTN, Parkinson's disease, depression, hyperlipidemia, and hemiplegia, and the facility policy required risk evaluation for bed rail use.
Inaccurate Bed Rail Assessments: The facility failed to complete ongoing accurate assessments for a resident’s right enabler side rail use. The resident had diagnoses including DM, hyperlipidemia, and depression, and the record showed quarterly bed rail evaluations stating bed rails were not recommended, yet a right enabler bar was observed on the bed and an RN confirmed the evaluations were not accurate.
Bed Rail Evaluations Not Completed Before Use The facility failed to complete bed rail evaluations for three residents who had bilateral 1/3 bed rails in use. One resident had severe cognitive impairment after a cerebral infarction and an incomplete bed rail evaluation remained in progress; another resident with hemiplegia, hemiparesis, and no decision-making capacity had bed rails ordered but no evaluation or care plan; and a third resident with a history of falls and bone density disorder had bed rails installed on readmission without a nursing evaluation. Staff confirmed the evaluations were not completed to assess appropriateness and entrapment risk.
Failure to assess entrapment risk and obtain informed consent for bed enabler bars. Two residents had bilateral enabler bars on their beds and were observed using them for positioning and bed mobility. One resident had dx including difficulty walking and muscle weakness; the other had repeated falls and generalized weakness. Surveyors requested documentation, but the facility could not provide entrapment zone measurements, and for one resident there was no informed consent documentation.
Failure to obtain informed consent for bed rails was identified for four residents. One resident had CVA-related deficits, blindness, muscle weakness, and an absent lower leg; another had Alzheimer’s disease, osteoporosis with fractures, reduced mobility, and muscle weakness; a third had adult failure to thrive and depression; and a fourth had adult failure to thrive, depression, and disorientation. Records included restraint or siderail assessments documenting quarter rails or upper side rails, but the EHRs lacked evidence of informed consent, and each resident was observed with upper side rails in place.
Improper Bed Rail Assessment and Use: The facility used grab bars as bed rails for multiple residents without completing the required pre-installation assessment process. Residents with diagnoses including muscle weakness, dementia, hemiplegia/hemiparesis, altered mental status, and fall history were observed with bilateral grab bars in place even when the BSA was incomplete, not recommended, or assessed for the wrong rail type. The QAN and DON stated grab bars are bed rails and that the required process was not followed.
Inaccurate Bedrail Care Plans and Missing Ongoing Assessments
Penalty
Summary
The facility failed to maintain accurate resident care plans and conduct ongoing accurate assessments for bedrail use for three residents. Facility policy stated that if a bed rail or side rail is used, the facility will evaluate the potential risks associated with bed rail use, including entrapment, before installation using the Bed and Bed Rail Safety Inspection Checklist. The report identified that the facility did not keep current assessments for Residents R2 and R14, whose beds had bilateral enabler bars observed during survey, and the last Enabler-Restraint Observation 2 assessment for each resident had been completed on 10/6/25. Resident R2 had diagnoses including high blood pressure, Parkinson's Disease, and anxiety, and had a physician order for a bariatric bed with bariatric mattress and bolster overlay and bilateral assistive handrails to aid with positioning, with placement checks every shift. Resident R14 had diagnoses including high blood pressure, hyperlipidemia, and depression, and had a physician order allowing grab/assist bars on the bed to promote independence and a sense of safety/security. Resident R160 had diagnoses including high blood pressure, hyperlipidemia, and hemiplegia, and bilateral enabler bars were observed on the bed, but the clinical record did not include an order or ongoing assessment for the enabler bar use, and the comprehensive care plan did not include measurable objectives, timetables, or specific interventions/services for the enabler bars.
Inaccurate Bed Rail Assessments
Penalty
Summary
The facility failed to conduct ongoing accurate assessments to ensure that bedrails were being used to meet a resident’s needs and to evaluate the risks associated with bedrail use for one of three residents. The facility policy dated 1/27/26 stated that the resident assessment must include an evaluation of alternatives attempted before installation or use of a bed rail and whether those alternatives were effective, and that assessment is to be completed at admission, re-admission, quarterly, annually, with significant change in condition, and when bed rails are added or removed. Resident R3 was admitted to the facility with diagnoses including diabetes, hyperlipidemia, and depression. The clinical record showed a physician order dated 2/23/26 for a right enabler side rail for positioning, and quarterly bed rail evaluations dated 3/18/26 and 6/19/26 both stated that bed rails were not recommended at that time. The current comprehensive care plan identified an ADL self-care deficit related to decline in overall function secondary to illness and included side rails (right enabler) for positioning. However, during an observation on 7/26/26 at 11:21 a.m., a right enabler bar was observed on the resident’s bed, and an RN later confirmed on 7/30/26 at 2:50 p.m. that the bed rail evaluations were not accurate.
Bed Rail Evaluations Not Completed Before Use
Penalty
Summary
The facility failed to ensure that a bed rail assessment was completed to evaluate risk for entrapment for three sampled residents who had bilateral 1/3 bed rails in use. The report states that the facility’s policy required a bed rail evaluation by a licensed nurse in collaboration with the IDT prior to use or installation of any bed rail on admission, readmission, or after a significant change in condition, including changes in mobility, cognition, behavior, or medical status. Resident 7 was admitted with diagnoses including unspecified sequelae of cerebral infarction and generalized muscle weakness. The MDS dated 5/12/2026 showed severe impairment in cognitive skills for daily decision making and extensive assistance needs for multiple ADLs and transfers. The care plan dated 6/11/2026 identified a potential for injury related to the use of bilateral 1/3 bed rails used as an enabler when in bed to assist with ADLs, transfers, and repositioning per resident/representative request, and it included evaluation of the ongoing need for bedrail use and assessment of entrapment risk prior to use. Observations on 7/21/2026 and 7/22/2026 showed the resident asleep in bed with bilateral 1/3 bed rails up. Review of the EMR on 7/22/2026 showed an order dated 6/12/2026 for the bed rails and a bed rail evaluation dated 5/21/2026 that was not filled out and remained in progress. RN 1 stated the evaluation was not completed and should have been completed to determine whether the bed rails were appropriate. Resident 104 was admitted with hemiplegia, hemiparesis following cerebral infarction affecting the left dominant side, and generalized muscle weakness. The H&P dated 7/16/2026 stated the resident did not have the capacity to understand and make decisions, had a fair prognosis for rehabilitation, and was on fall precautions. Observations on 7/21/2026, 7/22/2026, and 7/22/2026 showed the resident lying in bed with bilateral 1/3 bed rails up. Review of the EMR on 7/22/2026 showed an order dated 7/17/2026 for bilateral 1/3 bed rails used as an enabler when in bed to assist with ADLs, transfers, and repositioning per resident/representative request, but no bed rail evaluation or care plan for the bed rails. RN 1 confirmed that no bed rail evaluation or assessment and no care plan were present and stated the evaluation was needed to verify appropriateness of bed rail use. Resident 59 was admitted with a history of falling and a bone density disorder. The MDS dated [DATE] showed moderate impairment in cognitive skills for daily decision making and need for setup assistance with toileting hygiene, showering, lower body dressing, and footwear. On 7/22/2026, the resident was observed sleeping in bed with both 1/3 padded bed rails up. During record review, the MDS Nurse stated the resident had a physician’s order for the 1/3 bed rail on readmission but did not have a nursing bed rail evaluation prior to installation. RN 1 later reviewed the nursing bed rail evaluation and stated it had not been completed upon readmission and therefore the resident was not evaluated for entrapment risk. The facility’s P&P stated that bed rail risks, benefits, and need were to be evaluated prior to installation, including on admission, readmission, or after significant changes in condition.
Failure to Assess Entrapment Risk and Obtain Informed Consent for Bed Enabler Bars
Penalty
Summary
The facility failed to assess all potential risk areas for entrapment for two residents with enabler bars used as bed accident hazard devices, and failed to obtain informed consent for one resident's enabler bars. Resident 99 had diagnoses including difficulty walking and muscle weakness, a BIMS score of 15 indicating no cognitive impairment, and care plan interventions that included assist rails and bilateral grab bars to help with turning, repositioning, and bed mobility. During observation, bilateral enabler bars were attached to the resident's bed, and the resident stated he used them to help position himself. When surveyors requested documentation of informed consent, entrapment zone measurements, and risk assessments, the facility provided a nursing acknowledgement form dated January 17, 2025, but it did not include entrapment zone measurements, and the facility later stated it could provide no further documentation showing the potential entrapment zones were assessed. Resident 86 had diagnoses including repeated falls, a BIMS score of 14 indicating no cognitive impairment, and a care plan intervention that included grab bars on the bed to assist with bed mobility related to generalized weakness. During observation, bilateral enabler bars were present on the resident's bed, and the resident stated she used them to get in and out of bed. When surveyors requested documentation related to the enabler bars, the facility provided a nursing physical device review form dated March 23, 2026, but it did not contain entrapment zone measurements or documentation of informed consent. The facility later stated it could provide no further documentation showing the potential entrapment zones were assessed or that informed consent was obtained for the enabler bars.
Failure to Obtain Informed Consent for Bed Rails
Penalty
Summary
The facility failed to obtain informed consent from residents or their legal representatives before installing bed rails for four residents. R10 had diagnoses including cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting the right non-dominant side, blindness in the right eye, muscle weakness, and acquired absence of the right leg below the knee. The Restraint Use Assessment-V3 dated 01/09/2026 documented quarter bed rails to enhance bed mobility and stated they were not considered a restraint, but the EHR lacked evidence of informed consent. R10 was observed on 07/20/26 at 09:15 AM with upper side rails on each side of the bed. R14 had Alzheimer's disease, osteoporosis with femur fracture, fracture of the lower end of the left humerus, reduced mobility, muscle weakness, and difficulty walking, and the EHR lacked evidence of a bed rail assessment and informed consent; R14 was observed on 07/20/2026 at 08:29 AM with upper side rails on each side of the bed. R1 had adult failure to thrive and depression, and two Restraint Use Assessment-V3 entries documented quarter rails to enhance independence with bed mobility and transfers, but the EHR lacked evidence of informed consent; R1 was observed on 07/20/2026 at 09:25 AM with upper side rails on each side of the bed. R39 had adult failure to thrive, depression, and disorientation; the Siderail Assessment V1.0 dated 12/16/2025 documented impaired memory, cognition, or decision-making and conditions requiring increased safety measures, but the EHR lacked evidence of informed consent. R39 was observed on 07/20/2026 at 09:56 AM with upper side rails on each side of the bed.
Improper Bed Rail Assessment and Use
Penalty
Summary
The facility failed to ensure that bed rails or grab bars were properly assessed before installation for four sampled residents. The report states that the facility used the terms grab bars and bed rails interchangeably, and that the residents had orders for bilateral grab bars as aids to bed mobility, turning and repositioning, and transfers. The facility’s own policy required an interdisciplinary assessment, physician consultation, informed consent, entrapment assessment, and care plan inclusion before bed rail use. For Resident 54, the record showed diagnoses including muscle weakness, dementia, and hemiplegia/hemiparesis. The resident’s H&P stated the resident did not have capacity to understand and make decisions, and the MDS showed severe cognitive impairment and dependence for mobility and ADLs. Although the BSA dated 7/4/2026 stated that bed rails were not recommended by the IDT and physician, the resident was observed with bilateral grab bars in place. The QAN stated the grab bars were bed rails and that staff still applied them despite the BSA. For Resident 25, the record showed diagnoses including hemiplegia/hemiparesis and muscle weakness, and the H&P stated the resident could make needs known but could not make medical decisions. The BSA was incomplete and had no recommendation for bed rail use, while the resident was observed with bilateral upper grab bars on the bed. For Resident 26, the record showed reduced mobility, muscle weakness, and altered mental status, with the H&P stating the resident could make needs known but could not make medical decisions. The BSA stated grab bars were not recommended by the IDT and physician, yet the resident was observed sleeping in bed with bilateral grab bars in place and later again with bilateral upper grab bars on. For Resident 42, the record showed muscle weakness, history of falling, and hemiplegia/hemiparesis. The H&P stated the resident had capacity to understand and make decisions, and the MDS showed moderate cognitive impairment and a recent fall. The physician’s order was for bilateral grab bars, but the BSA assessed for 1/2 rails instead. The resident was observed in bed with bilateral grab bars on, and the QAN stated the assessment was for the incorrect bed rail type. The DON and QAN both stated that grab bars are an example of a bed rail and that the proper assessment process was not followed.
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