How facilities can avoid a F909 citation through bed audits, understanding and training around zones of entrapment, and more.
There is a grave misunderstanding around F909 that places your residents in danger and your facility at risk. In fact, on Polaris Mock Surveys conducted in the last 30 days, 85% of facilities were cited for F909 violations.
What is the misunderstanding?
Many facility staff believe that F909 is about checking resident beds, per the manufacturer’s instructions. Facilities often have the Maintenance Department maintain records which include verification that the bed operates properly, manufacturer information, serial numbers, and the date the bed was put into service.
This information is not enough because F909 is truly about resident safety specific to the fit of the mattress inside the bed frame.
Surveyors will be assessing entrapment risk and the physical environment of a resident’s bed. Entrapment is defined as an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail mattress or hospital bed frame. Facility staff are required to conduct regular inspections of all bed frames, mattresses, and bedrails to identify areas of possible entrapment to ensure compliance.
As a result of the misunderstanding about what surveyors are looking for in F909, F909 has been cited at a G or IJ Scope and Severity, regardless of whether actual harm to residents has occurred.
And when harm does occur, the consequences are devasting. Residents can suffer severe head, neck, or chest injuries, including suffocation and even death. CMS can apply substantial civil money penalties for these incidents and facilities also incur a negative impact on their reputation, litigation costs, and even criminal charges against facility personnel.
How can your facility promote resident safety and avoid resident entrapment?
- A mattress is a reason an entrapment zone may occur. Ensure your facility changes mattresses frequently, has a system to track changes, and there is a defined person who monitors and replaces mattresses.
- Whenever a change to the bed system occurs such as replacing a mattress or replacing a rail, a resident bed audit should be conducted. Your facility should have a process and designated person to monitor these changes.
- Ensure staff training about entrapment occurs.
- A Maintenance Department representative should attend daily stand-ups to ensure mattress changes have been communicated.
- Designate someone outside the Maintenance Department to spot-check compliance. Ask to see the documentation for bed frame audits from the past month to verify they are completed accurately and timely.
- Provide ongoing education to new Maintenance team members specific to this requirement. When making rounds, leadership should ask what compliance with F909 looks like to them.
- Implement a formal Bed Safety Program, including a policy regarding who is responsible for bed testing, what training is required, and at what intervals the testers should inspect the beds.
How Polaris Group Consultants Can Help
There are seven zones of entrapment and six are related to bedside rails. These zones should be listed on a resident bed audit tool. If your facility’s staff is unfamiliar with the seven zones of entrapment, Polaris Consultants can assist in implementing a Bed Safety Program for your facility, including audit tools to ensure compliance. Scheduling a Mock Survey is a great way to identify areas of risk and concern before harm occurs to residents.
