An Iowa nursing home was cited for placing its residents in immediate jeopardy after a resident became wedged between a bed and a grab bar and suffocated. According to the inspectors’ report, the facility had installed a positioning grab bar on the resident’s bed in June 2021 without first assessing the risk it might pose, and without obtaining consent from the resident’s family.
On March 19, 2022, a CNA went to the nurse’s station to report that the resident was on the floor. An LPN entered the room and noted the resident was entrapped with the right side of the head resting on the floor and the resident’s torso at the waist was between the headboard and the positioning grab bar. The County Medical Examiner stated that the resident died from positional asphyxiation.
The resident had experienced falls and was at risk for further falls related to polypharmacy. An intervention dated August 2, 2021, indicated a half rail was initiated to aid with transfers and establish boundaries. Additionally, an intervention initiated March 14, 2022, indicated that after repeated episodes of staff observing the resident putting him/herself on the floor intentionally, and additional multiple behaviors noted, a safety intervention of lowering the mattress to the floor and removing the bedframe was initiated to prevent injury. According to the DON, that intervention was never implemented and should have been removed from the care plan.
The RN on duty at the time of the resident’s death said the resident used the positioning grab bar when in bed to sit up on the side of the bed. She said she had not thought of the grab bar as a hazard since it was positioned far enough down that the resident’s head could not get trapped.
According to the inspection report, there was no documented evidence provided by the facility indicating the facility assessed the safety of the resident’s bed or implemented interventions to keep the resident safe. There was no documented evidence the facility conducted an ongoing assessment to ensure that the grab bar bed rail was meeting the resident’s needs, conducted an ongoing evaluation of risks, or identified who could determine when the bed rail could be discontinued as required per the facility’s “Bedrail Assessment” policy/procedure.
The maintenance supervisor said he had been working at the facility for two months and had never worked at a long-term care facility before. He stated he had been given paperwork with instructions on how to check mattresses and bed rails but had only looked at a few beds. The computer system that the facility used to keep track of work orders issued a monthly reminder to do bed checks, but he had not been doing them. He was scheduled to do his first checks on all the beds during the current month. He said he had marked the task as being completed because he did quick visual checks on the beds to make sure they were safe but did not realize there was more to do for the inspection and paperwork to be completed.
The facility also failed to ensure the incident resulting in the resident’s death was reported to the State Survey Agency (SSA) for possible neglect within two hours to meet abuse/neglect reporting requirements. Specifically, the facility failed to immediately report the event that resulted in the death of the resident. The facility submitted the incident report to the SSA 16.5 hours after the resident had been found deceased.
Issue:
CMS F700 Bed Rails states that a facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a side or bed rail is used, the facility must ensure correct installation, use, and maintenance of the rails. CMS states in F909 that a facility must conduct regular inspection of all bed frames, mattresses, and bed rails (if any) as part of a regular maintenance program to identify areas of possible entrapment. When bed rails or mattresses are used and purchased separately from the bed frame, the facility must ensure that the rails, mattress, and bed frame arecompatible. A bed gap analysis should be repeated each time a resident has a change of condition. Facilities also must ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after discovery if the allegation involves abuse or results in serious bodily injury, or not later than 24 hours if the allegation does not involve abuse and does not result in serious bodily injury.
Discussion Points:
- Review policies and procedures for resident safety, including fall prevention protocols, to ensure that they provide evidence-based interventions to reduce injuries and falls. Also review your policies and procedures for reporting of incidents/accidents to ensure they include current requirements.
- Train all appropriate staff on resident safety policies and procedures and on reporting requirements for events with and without serious injury. Also train appropriate staff including maintenance on the proper procedures for bed safety checks. Document that the trainings occurred, and file the signed documents in each employee’s education file.
- Periodically audit care plans to ensure that they are appropriate and contain evidence-based interventions to keep residents free from injury, that interventions are revised as needed, and that staff are informed of changes. Audit to make sure bed safety checks are being done regularly and correctly. Also audit your incident/accident reports to ensure that all issues where reporting is required were managed timely with appropriate follow-up. You can obtain a useful resource for conducting entrapment risk checks for all beds, whether bed rails are in use or not, at the following link: Guidance for Industry and FDA Staff – Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment.
