F0558

D

Failure to Provide Ordered Bariatric Bed and Side Rails for Obese, High-Risk Resident

Whittier, California Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to reasonably accommodate a resident’s assessed need and physician’s order for a bariatric bed with bilateral 1/2 side rails. The resident had diagnoses including obesity due to excess calories, hyperlipidemia, major depressive disorder, respiratory failure with hypoxia, CKD, HTN, pneumonia, CHF, COPD, asthma, neuropathy, depression, impaired mobility, and incontinence. The resident’s H&P documented capacity to understand and make decisions. The physician’s order summary and the resident’s care plans specified the use of a bariatric bed with bilateral 1/2 side rails as an intervention, including for assistance with turning and as part of fall risk interventions that also called for side rails as ordered and a safe environment.

On readmission, the resident was placed in a regular bed without side rails, despite the existing physician’s order and care plan interventions for a bariatric bed with 1/2 side rails. Nursing notes documented that the resident initially refused to change to a bariatric bed, stating a desire to rest. The DON later confirmed that a bariatric bed had been used prior to the recent hospitalization and that the bariatric bed was available and in the hallway at the time of readmission. The Maintenance Supervisor confirmed that the bed in the room at readmission was a regular bed, not a bariatric bed. Staff interviews indicated that the resident was “really big,” almost 300 lbs, and barely fit in the regular bed, and that the readmission bed did not have side rails.

During the night shift following readmission, an LVN reported speaking with the resident about the new room and that the resident mentioned needing a bigger bed and that the current bed needed to be switched out. The LVN did not offer to switch the bed and did not change the bed to a bariatric bed despite this request and the existing order. Later that night, the resident’s roommate found the resident on the floor between the two beds, unresponsive, and called for help. Staff found the resident lying on her left side, unresponsive, not breathing, and without a pulse. Emergency protocols were initiated, including CPR, and emergency services were contacted. The resident was later pronounced deceased, with the medical examiner determining the manner of death as natural, caused by congestive heart failure and obesity. The facility’s policies on admissions and resident safety required that physician orders be noted and initiated and that room checks and bedside observations be conducted to ensure a safe environment, but the ordered bariatric bed with side rails was not in place at the time of the event.

The facility’s fall risk care plan for the resident identified her as at risk for falls related to multiple comorbidities and impaired mobility and specified that side rails be used as ordered and that a safe environment be maintained, including appropriate assistive devices. The DON stated that the 1/2 side rails were used as an enabler for the resident. Despite this, the resident remained in a regular bed without side rails from the time of readmission through the time she was found on the floor. Multiple staff, including the DON, LVNs, and the Maintenance Supervisor, acknowledged the discrepancy between the physician’s order and care plan interventions and the actual bed provided and maintained for the resident during this period.

The nursing progress notes and staff interviews further showed that the resident’s refusal of the bariatric bed at the time of readmission was documented but not followed by any documented reassessment or alternative accommodation when the resident later expressed a need for a bigger bed. The facility’s own policies required that physician orders be initiated at admission and that safety measures, including appropriate assistive devices and room setup, be in place. Nonetheless, the ordered bariatric bed with 1/2 side rails was not implemented, and the resident remained in a regular bed without side rails until she was discovered on the floor, unresponsive.