LAFAYETTE, LA - River Oaks Retirement Manor received immediate jeopardy citations during an August 2024 inspection after regulators discovered the facility had been attaching wooden boards to bed rails without manufacturer approval, a practice that contributed to a resident becoming trapped between a bed rail and air mattress.
Unauthorized Equipment Modifications Created Safety Hazards
State inspectors found that maintenance staff at River Oaks had been routinely attaching wooden boards to standard bed rails on beds equipped with air mattresses, creating a configuration never approved by the equipment manufacturers. This modification was in place for multiple residents and had been standard practice at the facility for years.
The investigation revealed that maintenance personnel installed these wooden board attachments without consulting manufacturer guidelines or safety specifications. When questioned, the maintenance supervisor stated he "simply did what the facility had always done" and had never referred to manufacturer recommendations to ensure the beds, mattresses, and modified rails were compatible and safe.
Air mattresses sit higher than standard mattresses, and the facility's rationale for adding wooden boards was to prevent residents from falling out of bed. However, this well-intentioned modification created an entirely different safety hazard. The wooden boards created a rigid barrier between the inflated air mattress and the bed rail, forming a gap where residents could become wedged if they rolled toward the edge of the bed.
Medical equipment manufacturers conduct extensive safety testing and provide specific guidelines for how their products should be used together. When facilities make unauthorized modifications, they bypass these safety standards and create unpredictable risks. Bed rail entrapment can restrict breathing, cut off circulation, and cause serious injuries or death, particularly for residents with limited mobility who cannot free themselves.
Facility Administration Continued Unsafe Practice Despite Known Risks
Following a serious incident on July 30, 2024, where a resident became entrapped between a boarded bed rail and air mattress and required hospitalization, facility leadership made a troubling decision. Rather than immediately removing all similar configurations from other residents' rooms, they replaced only the affected resident's bed and allowed four other residents to remain in beds with the same potentially dangerous setup.
During interviews on August 6, 2024, the Director of Nursing acknowledged that "there was a risk for any resident with bed rails to become entrapped between the bed rails and the mattress." Despite this acknowledgment, she stated that administration believed "the benefits of the boarded bed rails outweighed the risks" and that leadership "still felt the boarded bed rails were safe even if a resident was able to roll and become entrapped."
This decision violated fundamental healthcare safety principles. When a serious safety event occurs, standard practice requires immediate assessment of whether similar risks exist elsewhere in the facility and prompt corrective action. The facility's choice to continue the practice for other residents while knowing about the entrapment risk represented a failure in safety management.
The administrator acknowledged he had questioned the wooden board modification when he first joined the facility but "just went with it because there were no resident complaints or issues." This reactive approach to safety—waiting for problems to occur rather than proactively verifying equipment compatibility—placed vulnerable residents at ongoing risk.
Inadequate Safety Assessments and Monitoring Protocols
Inspectors found significant deficiencies in how the facility assessed and monitored residents using bed rails. The bed rail assessments completed by MDS nurses failed to include essential information such as resident height and weight measurements or bed dimensions—critical data needed to ensure proper fit and safety. The assessments also failed to document whether staff had attempted alternative fall prevention interventions before resorting to bed rails.
Care plans for the five affected residents contained no specific safety interventions addressing the modified boarded rails, no provisions for increased monitoring, and no protocols for preventing entrapment. Nursing staff were instructed only to document during rounds that bed rails were "in place as ordered," with no specific guidance on assessing entrapment risks or mattress positioning.
Standard practice for bed rail safety requires detailed assessments of the specific bed-rail-mattress combination, documentation of the resident's physical characteristics and mobility level, and clear monitoring protocols. Facilities should evaluate whether the mattress fits properly within the bed frame, whether gaps exist that could allow entrapment, and whether the resident's condition creates elevated risk factors.
Following the July incident, the facility provided training to certified nursing assistants on not moving a resident if they became entrapped in side rails, but provided no training on how to prevent entrapment from occurring in the first place.
Additional Issues Identified
Inspectors discovered that mattress stabilizers had been attached to the corners of several beds, preventing air mattresses from lying flush on the bed frames and causing instability. These stabilizers were removed during the inspection, though it remained unknown whether they had contributed to the original entrapment incident. The facility was unable to provide manufacturer guidelines for either the beds or mattresses during the inspection, and maintenance staff confirmed they had no documented evidence of routine safety inspections for the modified bed rail systems.
The facility's policy required following manufacturer recommendations, but staff across multiple departments confirmed this policy was not being implemented for the bed rail modifications. The administrator stated the facility had been gradually replacing older beds but had not prioritized replacing beds for the four residents still using the modified boarded rails due to cost considerations.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for River Oaks Retirement Manor from 2024-08-08 including all violations, facility responses, and corrective action plans.
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