SIOUX FALLS, SD - State health inspectors identified immediate jeopardy conditions at Good Samaritan Society Sioux Falls Village after discovering widespread bed rail safety violations that placed residents at risk of entrapment, falls, and serious injury. The April 2025 inspection documented improperly installed and maintained bed equipment throughout the 159-bed facility, prompting emergency corrective actions.
Widespread Equipment Failures Create Entrapment Hazards
The inspection revealed systemic failures in bed rail installation and maintenance affecting at least 26 residents. Inspectors documented loose, improperly secured grab bars and side rails that lifted mattresses when pulled, creating dangerous gaps where residents could become trapped. In multiple rooms, bed rails were not securely attached to bed frames, and mattresses could be elevated when the rails were moved.
The violations were particularly concerning given that many affected residents actively relied on these devices for mobility and repositioning. Resident 137 told inspectors she was aware her grab bar was loose and indicated she would have tightened it herself if she had a screwdriver. This statement highlights both the duration of the maintenance failures and residents' awareness of the dangerous conditions.
The facility's bed rail configurations violated fundamental safety standards. Gaps exceeding five inches were documented between mattresses and headboards in seven residents' rooms, creating zones where limbs, heads, or torsos could become wedged. Additionally, inspectors found exposed metal installation holes in five residents' rooms where bed rails had been removed but the mounting hardware remained, presenting sharp edges that could cause lacerations or other injuries.
Critical Safety Assessment Failures
Beyond the physical equipment problems, the facility failed to properly assess and document residents' use of bed rails as required by federal regulations. Resident 356 was using side rails without having a completed Physical Device and/or Restraint Evaluation and Review assessment, a fundamental requirement for determining whether such devices are appropriate and safe for individual residents.
The inspection revealed that even when assessments were completed, they were often inadequate. Multiple resident assessments failed to document any alternatives that had been attempted before implementing bed rails. The assessments also lacked documentation of safety risk evaluations for potential entrapment, accident hazards, or negative physical and psychological outcomes. No evidence existed that residents or their families received education about the proper use and risks associated with bed rails.
These assessment failures are particularly dangerous because bed rails are not universally safe for all residents. Cognitively impaired residents may attempt to climb over rails, increasing fall risk from greater heights. Physically frail residents may lack the strength to free themselves if trapped between the rail and mattress. Without proper assessment, facilities cannot determine which residents can safely use these devices or identify those who need alternative interventions.
Incompatible Equipment and Broken Components
The inspection uncovered that the facility was using bed rail models incompatible with their Hill-Rom spring bed frames, directly contradicting manufacturer instructions. This mismatch between equipment components significantly increased safety risks and likely contributed to the widespread loosening and instability problems documented throughout the facility.
Resident 103's situation exemplified the severity of the equipment failures. Her bed rail was broken and not secured to the spring bed frame. When weight was applied to the bed rail as if a resident were using it for mobility and stability, the bed rail buckled backwards, potentially creating a fall hazard. The particleboard grab bar frame beneath her mattress was broken in one corner, creating additional injury risks from splintered wood and unstable support structures.
The use of particleboard frames as makeshift mounting systems for bed rails represents a significant departure from proper installation methods. These improvised solutions lack the structural integrity needed to support residents' weight during transfers or repositioning, dramatically increasing the risk of sudden equipment failure and resident falls.
Medical Implications of Bed Rail Hazards
Bed rail entrapment represents one of the most serious safety risks in long-term care settings. When residents become trapped in gaps between the mattress and rail, or between rail components, they can experience positional asphyxiation within minutes. The compression of the chest or neck restricts breathing, while trapped limbs can suffer circulation loss leading to tissue damage or amputation.
The loose and unstable bed rails documented at the facility created multiple entrapment zones. The seven identified areas where gaps exceed FDA guidelines, combined with rails that lifted mattresses when pulled, formed perfect conditions for entrapment incidents. Elderly residents with limited mobility or cognitive impairment may not recognize the danger or be able to extricate themselves once trapped.
Falls from bed represent another critical risk when bed rails fail. Residents who rely on these devices for support during transfers can experience catastrophic falls if the equipment suddenly gives way. Hip fractures from such falls often result in permanent disability or death in elderly populations, with mortality rates approaching 30% within one year of injury.
The exposed metal mounting holes discovered in five residents' rooms presented additional injury mechanisms. These sharp edges could cause severe lacerations if residents made contact during transfers or repositioning. For residents on anticoagulant therapy, common in nursing home populations, even minor cuts from these hazards could result in dangerous bleeding episodes.
Additional Issues Identified
The inspection documented numerous other safety violations beyond the primary bed rail concerns. Maintenance staff had not been conducting regular preventive maintenance checks on bed equipment, allowing dangerous conditions to persist undetected. The facility lacked a systematic approach to bed safety assessments and had no process for ensuring new admissions received proper equipment evaluations.
Staff education regarding entrapment risks was insufficient, with no evidence of training on recognizing hazardous conditions or responding to entrapment emergencies. The facility's quality assurance program had failed to identify these widespread safety issues through internal audits or monitoring systems.
Documentation deficiencies extended beyond missing assessments. Care plans did not reflect residents' actual use of bed rails or address associated safety considerations. Physician orders for bed rails lacked supporting documentation explaining medical necessity or consideration of less restrictive alternatives.
Immediate Corrective Actions Required
Following the immediate jeopardy designation on April 16, the facility implemented an emergency correction plan. All 26 identified residents had their bed equipment addressed within hours, with assist bars removed from 17 beds, one bed completely replaced, and footplates installed to eliminate dangerous gaps. The facility conducted a comprehensive audit of all 159 residents' beds and initiated staff education via mobile messaging systems.
The correction plan established new monitoring protocols including weekly audits for four weeks followed by biweekly checks for two months. Maintenance staff received training on bed inspection procedures, and the facility committed to reviewing all new admissions during daily clinical meetings to ensure proper assessment completion.
Moving forward, the facility must maintain these enhanced safety protocols while addressing the systemic failures that allowed such widespread violations to develop. Proper equipment compatibility, regular maintenance schedules, comprehensive assessments, and ongoing staff training are essential to prevent recurrence of these dangerous conditions that threatened residents' safety and well-being.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Good Samaritan Society Sioux Falls Village from 2025-04-24 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.