Failure to Ensure Bed Rail Safety Leads to Resident Death
Summary
The facility failed to ensure the correct installation, use, and maintenance of bed rails, leading to a significant safety risk for 55 residents. Specifically, the facility did not inspect and regularly check the mattress and bed rail for areas of possible entrapment. This oversight was evident in the case of a resident with a contour mattress and a right side bed rail, where the facility did not evaluate alternatives to bed rails, review the risks and benefits with the resident or their representative, or obtain informed consent prior to the installation of bed rails. The deficiency was highlighted by a tragic incident involving a resident diagnosed with Alzheimer's disease, who was found with their head wedged between the bed rail and the mattress, resulting in their death. The resident was last observed at approximately 4:30 AM for incontinence care, and at 5:45 AM, they were found in a kneeling position beside the bed, with no pulse or respirations. The cause of death was listed as probable positional asphyxiation. Interviews with facility staff revealed a lack of familiarity with guidelines for the prevention of bed entrapment and an absence of specific measurements regarding entrapment risk zones. Maintenance staff were responsible for installing bed rails and performing bed safety checks, but they did not have a process for measuring entrapment risk zones. The facility's policy did not include entrapment guidelines, and there was no documented evidence that beds were measured for entrapment risk, putting residents at risk for serious injury or death.
Removal Plan
- Maintenance was trained on entrapment zones and how to measure per FDA guidelines.
- An audit tool that contained all aspects of bed safety, compatibility of bed, mattress, and bed rails; mattress inspection, and entrapment zones was completed for all beds in the facility.
- The updated bed rail policy and procedure was provided which included Maintenance will check the bed model and install a compatible bed rail. Once installed the bed will be checked prior to use for entrapment zones, and if any are determined to be non-compliant the device will be un-installed immediately and nursing will be informed. Maintenance will close out the work order ticket once completed and update nursing of completion. Staff education was completed.
- A bed rail process and procedure audit tool was developed to monitor alternatives tried, bed rail assessment completed, Interdisciplinary Team review, care plan update, consent after provision of information, order in place, maintenance measured, monitoring resident safety, and physical restraint assessment.
- Continued education provided to all direct care workers, housekeeping, maintenance, social work, therapy, and activities are reminded of bed safety, entrapment zones, bed placement and potential for creating entrapment zones. Mattresses should not move on the bed frame. Mattress stops located on the 4 corners of the bed frame. Staff are responsible for reporting any entrapment zone issues or concerns. All staff who are actively employed by the facility have been trained.
- Education of staff that has not received training (due to illness, vacation, or leave of absence) will be completed before reporting to their workstations on their next schedule day.
Penalty
Resources
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Bed rails were used for three residents without the required documentation and authorization. One resident with hemiplegia and fluctuating decision-making capacity had bilateral half side rails in use, but RN and DON stated there was no current physician order or care plan for side rail use. Two other residents, including one with Alzheimer's disease and seizures and another with hemiplegia and intact cognition, had orders and assessments for 1/4 rails, but were observed or documented with 1/2 rails instead; the DSD and DON stated the specific 1/2 rail use lacked the proper order, informed consent, assessment, and care plan.
A resident with intracranial hemorrhage, respiratory failure, and hypertensive emergency was observed with all four bed rails raised, even though the physician's order and informed consent only addressed bilateral upper half side rails. Staff interviews confirmed the resident was being positioned with four side rails without a specific order or consent for that setup, and the facility policy required informed consent before bed rail use.
The facility failed to complete ongoing accurate assessments for bedrail use for two residents. One resident had weakness, a right BKA, and bilateral enabler bars, while another had CVA with left-sided paralysis and a left enabler bar. Both residents’ last Enabler/Assist Rail/Device Evaluation - V2 assessments were completed about a year earlier, and the ADON confirmed assessments should be done quarterly.
A resident with intact cognition and multiple serious diagnoses had half bedrails placed on both sides of his bed without a documented side rail assessment, informed consent, or evidence that alternatives were tried first. Staff interviews showed the Maintenance Supervisor was told to install the rails without being shown a signed consent, while RN and ADON staff were unaware the rails were in place or that the required documentation was missing. The resident stated he did not request the bedrails and was never spoken to about them.
A resident with severe cognitive impairment and a history of recent falls was repeatedly observed asleep in bed with bilateral upper grab rails elevated. The care plan, updated after the falls, included side rails as grab bars for fall prevention and assistance with repositioning, but the bed rail assessment documented that side rails or assist bars were not indicated, and no bed rail entrapment risk assessment was found. Staff interviews confirmed that the resident used the grab rails for turning and repositioning and that the care plan called for grab bars despite the assessment indicating otherwise, resulting in a deficiency for failing to ensure safe and properly assessed side rail use.
The facility failed to document alternative measures, risk-benefit discussion, and informed consent before side rail use for two residents. One resident with ESRD and severe cognitive impairment and another resident with dementia and intellectual disabilities were observed with side rails raised in bed, but records showed no current order for side rails and no documented evidence that alternatives were explored or that risks and benefits were reviewed with the resident or RP.
Bed rails used without required orders, consent, assessments, and care plans
Penalty
Summary
The facility failed to safely use bed rails for three sampled residents by not ensuring the required physician orders, informed consent, bed rail assessments, and care plans were in place for the specific bed rail use observed. The report states that the facility used bed rails without meeting its own criteria for use, and that staff and leadership acknowledged the need for a resident assessment, entrapment assessment, consent, physician order, and care plan before bed rails are used. Resident 11 was admitted with diagnoses including hemiplegia, hemiparesis following cerebral infarction, type II DM, and generalized muscle weakness. The H&P noted fluctuating capacity to understand and make decisions. The MDS showed the resident needed supervision or touching assistance with toileting, personal hygiene, showering, and lower body dressing, and was independent with rolling and sit-to-lying. During observation, the resident was seen in bed with bilateral side rails elevated, and CNA 4 stated the resident requested the side rails be elevated at all times. RN 5 reviewed the record and stated there was no current physician order for side rail use and no care plan documented for side rail use. The DON stated side rail use required assessment for risks and benefits, entrapment assessment, consent, a physician order, and inclusion in the comprehensive person-centered care plan. Resident 22 had diagnoses including Alzheimer's disease, contracture, and seizures, and the H&P stated the resident did not have capacity to understand and make decisions. The MDS indicated severely impaired cognition and dependence for mobility and ADLs. The OSR contained an order for padded side rails up times 2 top of quarter for mobility/enabler every shift for seizures, and the BRERO assessed quarter rails. However, during observation the resident's bed rails were identified as 1/2 length. The DSD stated the resident had an order for 1/4 padded side rails/bedrails but no order for the 1/2 bed rails actually in use, and that the BRERO and consent were for a 1/4 bed rail. Resident 163 had diagnoses including hemiplegia, hemiparesis following cerebral infarction, and disorders of bone density and structure of the left hand. The MDS showed intact cognition and dependence to partial assistance with mobility and ADLs. The OSR ordered may have 1/4 side rails up x 2 for mobility aid, and the BROA assessed bilateral 1/4 bedrails, but the DSD stated the resident was on 1/2 bed rails without a specific order, informed consent, bed rail assessment, or care plan for that use.
Failure to Obtain Consent and Order for Four Side Rails
Penalty
Summary
The facility failed to obtain consent and a physician's order for the use of four side rails for Resident 116. Resident 116 was admitted with diagnoses including nontraumatic intracranial hemorrhage, respiratory failure, and hypertensive emergency. The MD progress notes dated 7/9/2025 indicated the resident did not have the capacity to understand and make decisions. The physician's order dated 1/8/2026 directed bilateral upper half siderails up and locked when in bed for ADL changes, and the resident's informed consent dated 7/9/2025 also addressed bilateral upper half side rails up when in bed secondary to involuntary movement by gravity due to elevated head of bed for management and provision of enteral feeding. During observation on 4/20/2026, Resident 116 was seen in bed with upper and lower bed side rails raised on both sides, and later with the left and right upper side rails raised and the right lower side rail raised while CNA 3 stated the resident was supposed to have all four side rails raised up. DSD later stated the resident should only have upper side rails up per the physician's orders. ADON 1 reviewed the informed consent and stated there was no informed consent or physician's order for all four side rails, and that a specific informed consent and physician's order were required for four side rails. The facility policy stated bed rails are prohibited unless criteria are met and that informed consent must be obtained before using bed rails.
Failure to Reassess Bedrail Use and Risk
Penalty
Summary
The facility failed to conduct ongoing accurate assessments to ensure that bedrails were used to meet residents’ needs and to evaluate the risks associated with bedrail use for two residents. Facility policy titled Proper use of Bed Rails, dated 1/15/26, required resident assessment of risk from using bed rails, including risk of entrapment between the mattress and bed rail or in the bed rail itself, with reassessments at least quarterly, after a significant change in status, or when the type of bed, mattress, or rail changed. Resident R3 was admitted with diagnoses including high blood pressure, hyperlipidemia, and muscle weakness, and the care plan identified an ADL self-care deficit related to weakness/deconditioning and a right below-the-knee amputation, with bilateral enabler bars used to assist mobility. The last Enabler/Assist Rail/Device Evaluation - V2 assessment for R3 was completed on 4/11/25, yet bilateral enabler bars were observed on the bed during an observation on 4/13/26. Resident R7 was admitted with diagnoses including high blood pressure, hemiplegia, and CVA, and the care plan identified an ADL self-care deficit related to CVA with left-sided paralysis, with a physician order for a left enabler bar to assist with mobility and positioning. The last Enabler/Assist Rail/Device Evaluation - V2 assessment for R7 was also completed on 4/11/25, and a left enabler bar was observed on the bed during the same observation date. The ADON stated that enabler bar assessments should be done quarterly and confirmed the facility failed to conduct ongoing accurate assessments for these two residents.
Bedrails Installed Without Assessment or Informed Consent
Penalty
Summary
The facility failed to attempt alternatives before installing half bedrails on both sides of Resident #9's bed, failed to obtain informed consent before installation, and failed to ensure correct installation and maintenance of the bedrails. Record review showed that Resident #9 was a cognitively intact male with a BIMS score of 15 and diagnoses including type 2 diabetes mellitus, cerebrovascular accident, bilateral below-the-knee leg absence, and dependence on renal dialysis. His MDS did not address bedrail use, and his care plan addressed bed mobility assistance but did not reflect bedrails. The EHR also showed no side rail evaluation. Observation on 04/14/26 showed half bedrails on both sides of Resident #9's bed. The Maintenance Supervisor stated that the previous DON told him to place the bedrails on the resident's bed, but he was not shown a signed consent despite asking for it. He stated he understood consent was needed to show the resident had been evaluated and agreed to the bedrails, and he said he should have notified the Administrator before installing them when consent was not provided. He also stated he checks the rails weekly to ensure they are securely placed. Interviews showed staff were unaware of the bedrails or the required documentation. RN B stated she did not know Resident #9 had half bedrails and said she did not believe they were a restraint, though she acknowledged a resident could get an arm stuck and be hurt and that an assessment should be completed before bedrails are placed. ADON C stated Resident #9 should have had an assessment, care plan, and consent, and the DON stated residents with half bedrails should have a bedrail assessment, consent, care plan intervention, and nurse documentation. Resident #9 stated he did not request the bedrails, no staff spoke with him about them, and he was not given a consent or assessment. The facility policy stated alternatives should be attempted before installing bedrails and that assessment, informed consent, and proper installation and maintenance were required.
Inconsistent Bed Rail Assessment and Use After Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s use of side rails was consistent with the facility’s bed safety policy and the resident’s own assessments and care plan. The facility’s policy required the IDT to assess the resident’s sleeping environment, consider safety, medical conditions, comfort, freedom of movement, and input from the resident/family, and to use side rails only when needed to manage a medical symptom or to assist with repositioning or transfers when no other reasonable alternatives were identified. Surveyors observed the resident on multiple occasions lying in bed asleep with bilateral upper grab rails elevated. The resident’s MDS showed severe cognitive impairment, no impairment to upper or lower extremities, and a need for staff supervision for bed mobility. Progress notes documented that the resident was found on the floor on one occasion and kneeling on a floor mat on another occasion. Following these falls, the resident’s plan of care was updated with a problem addressing an actual fall, and the interventions included providing side rails to be used as grab bars. However, the resident’s Bed Rail Assessment dated the same month indicated that side rails or assist bars were not indicated for this resident, and there was no documentation of a bed rail entrapment risk assessment being conducted at that time. During interviews, a CNA confirmed that the resident used the grab rails to hold on when turning and repositioning, and an RN confirmed that the fall care plan interventions included grab bars while also verifying that the bed rail assessment showed grab rails were not indicated. This inconsistency between the care plan, the bed rail assessment, and the actual use of side rails led to the cited deficiency for failing to ensure the resident was free from accident hazards related to side rail use.
Failure to Document Alternatives, Risk-Benefit Discussion, and Informed Consent for Side Rail Use
Penalty
Summary
The facility failed to ensure that alternative measures were tried before side rails were used, and failed to document discussion of risks versus benefits and obtain informed consent for side rail use for two residents. The report states that these issues were identified for R3 and R6 during observation, interview, record review, and policy review. The deficiency involved side rail use without a current physician order and without the required documentation in the residents’ records. R3 was admitted with end stage renal disease and had a BIMS score of 3, indicating severe cognitive impairment. R3’s care plan listed upper side rails for mobility, and during observation R3 was resting in bed with the head of bed upright and side rails up on both sides. The side rail/entrapment evaluation for R3 showed no documentation that alternatives were explored before bed rail use, and there was no documentation of risks versus benefits or informed consent. The RNN stated the facility did not try alternatives before bedrail use for R3, did not discuss risks and benefits, and had nothing for the resident to sign for informed consent. R6 was admitted with mild intellectual disabilities and dementia and also had a BIMS score of 3. R6’s care plan included side rails up while in bed to aid in bed mobility and transfers, and during observation R6 was lying in bed with the head of bed elevated and bilateral half side rails raised. The side rail evaluation completed after the surveyor identified concern showed side rails were used, but the record contained no documented evidence of what alternatives were explored before implementation and no documented evidence that risks versus benefits were explained to the responsible party or that informed consent was obtained. The facility policy stated bedrails could be considered a form of physical restraint and that the need for bedrails should be identified in the resident assessment and plan of care.
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