GREENDALE, WI - A Wisconsin nursing home faced significant safety violations after inspectors found that staff failed to conduct proper fall investigations and placed bed rails on a resident's bed without completing required safety assessments.
Incomplete Fall Investigation After Bed Rail Entrapment Incident
Heritage Square Health Care Center in Greendale received citations following a December 2024 incident involving a resident whose arm became trapped in bed rails during a fall. The facility's investigation of the incident contained multiple discrepancies and failed to identify the root cause of the fall, according to inspection findings.
The resident, identified as R8, was discovered on December 22, 2024, in a compromised position after attempting to get out of bed. According to nursing staff, R8 had his left arm stuck in the bed rail and staff were unable to remove his arm, requiring them to contact Emergency Medical Services. However, the facility's official fall investigation documented conflicting accounts of how the resident was found and what occurred during the incident.
The investigation revealed concerning gaps in the facility's response. While R8 told inspectors during interviews that "his left arm got stuck in his bed rail, so he put himself on the floor to help get his arm out," the facility's documentation failed to adequately address this entrapment risk or investigate why the bed rails posed a safety hazard for this particular resident.
Medical Significance of Bed Rail Entrapment
Bed rail entrapment represents a serious safety concern in nursing homes, particularly for residents with limited mobility. When residents become trapped between bed rails and mattresses or within the rail structure itself, they face risks of injury, circulation compromise, and psychological trauma. The incident highlights the critical importance of individualized bed rail assessments.
R8's medical conditions - including muscle wasting, mobility impairments, and dementia - created specific risk factors that should have been carefully evaluated before bed rails were installed. Residents with these conditions may have altered judgment about safe movement and may lack the physical strength to extract themselves if entrapment occurs.
The facility's own policy required comprehensive risk assessments before bed rail installation, including evaluation of entrapment risks between the mattress and bed rail. This assessment should consider the resident's size, cognitive status, mobility level, and medical conditions to determine whether bed rails would enhance or compromise safety.
Bed Rails Installed Without Proper Assessment
Inspectors discovered that R8 had bed rails placed on his bed without completion of the required safety assessment. The facility's therapy director acknowledged that an assessment is required prior to any bed rails being placed on a resident's bed, yet R8's rails were installed when he moved to a different bed, with the assessment completed only after his entrapment incident.
According to facility policy, bed rail decisions should follow a person-centered approach with alternative interventions attempted first. The policy specifically requires assessment of entrapment risks and informed consent from residents or their representatives. For R8, this process occurred in reverse - bed rails were installed first, the incident occurred, and only then was a safety assessment completed on December 23, 2024.
The facility's approach violated established protocols that prioritize resident safety through preventive assessment rather than reactive evaluation after incidents occur. Industry standards emphasize that bed rail decisions must be individualized, with ongoing monitoring to ensure continued appropriateness.
Inadequate Post-Incident Response and Reassessment
Following the December incident, the facility failed to adequately reassess whether bed rails remained appropriate for R8. Despite his arm becoming trapped and requiring emergency intervention, therapy staff determined during a December 23 assessment that R8 was still "safe for bed rails" without conducting a thorough re-evaluation of alternatives.
The Director of Therapy told inspectors that the next bed rail assessment would be completed quarterly or by nursing requests, suggesting no immediate reassessment was planned despite the incident. This approach conflicts with best practices that call for immediate reassessment whenever a resident experiences complications related to bed rails.
Proper post-incident protocols should have included removal of bed rails pending comprehensive reassessment, exploration of alternative safety measures, and interdisciplinary team review of R8's care plan. The facility's decision to maintain bed rails without addressing the underlying factors that led to entrapment raised concerns about resident safety prioritization.
Care Plan Modifications Fall Short of Addressing Root Causes
While the facility updated R8's care plan after the incident to include more frequent toileting assistance, inspectors noted that these modifications failed to address the fundamental issue of bed rail appropriateness. The care plan focused on preventing future falls through environmental modifications rather than addressing whether bed rails created additional safety risks for this resident.
R8's documented dependency for bed mobility and transfers raised questions about the therapeutic benefit of bed rails versus their potential for harm. Nursing assistants confirmed that R8 is unable to roll himself side to side independently and requires staff assistance even to grab bed rails during care activities.
Additional Issues Identified
The inspection also documented inconsistencies in staff statements about the fall incident, inadequate documentation of the resident's position when discovered, and failure to obtain witness statements as required by facility policy. Administrative staff acknowledged the concerns raised by inspectors but provided no additional information to address the identified deficiencies.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bedrock Hcs At Greendale LLC from 2025-01-08 including all violations, facility responses, and corrective action plans.
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