F0700

D

Failure to Assess, Obtain Orders, and Secure Informed Consent Before Installing Bed Grab Bars

Bell Gardens, California Survey Completed on 01-21-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its own process and policy for bed safety and bed rail use before installing bilateral grab bars on the beds of two residents. For the first resident, who had diagnoses including generalized muscle weakness, dementia, and chronic atrial fibrillation, the admission record showed a responsible party, and the MDS dated 11/2/2025 indicated severely impaired cognition with dependence on staff for toileting, bathing, and lower body dressing. The H&P dated 6/9/2025 documented that this resident did not have the capacity to understand and make decisions. Despite this, during observations on 1/20/2026, the resident was seen lying in bed with bilateral grab bars in place, which RN 1 stated were used to aid in bed mobility and repositioning.

During concurrent record review for the first resident, the Side Rail Utilization Assessment dated 11/2/2025 indicated that the resident did not have side rails currently in use or requested, even though grab bars were present on the bed. RN 1 stated she did not know when the grab bars were installed and acknowledged that an accurate side rail utilization assessment should have been completed to ensure the resident was safe and able to use the grab bars. Review of the active physician orders on 1/20/2026 showed no order for bilateral grab bars. RN 1 stated that an order was necessary to inform the physician of the need for grab bars and to allow the physician to determine whether installing them was safe, and that grab bars had the potential to be used as a restraint. Review of the electronic health record on 1/20/2026 showed no documentation that informed consent had been obtained from the responsible party for the use of grab bars, and RN 1 confirmed there was no documentation of informed consent.

For the second resident, the admission record showed initial admission and readmission dates, with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left side, lack of coordination, and weakness. The MDS indicated moderately impaired cognition and dependence on staff for toileting, bathing, and lower body dressing. The H&P dated 6/25/2025 documented that this resident did not have the capacity to understand and make decisions and identified a surrogate decision-maker. On 1/20/2026, the resident was observed lying in bed with bilateral grab bars, which RN 1 stated were used to aid in repositioning. However, the Side Rail Utilization Assessment dated 1/14/2026 indicated that the resident did not have side rails currently in use or requested, and RN 1 did not know when the grab bars were installed. Review of active orders on 1/20/2026 showed no order for bilateral grab bars, and RN 1 confirmed there was no order for their use. The electronic health record on 1/20/2026 contained no indication that informed consent for grab bar use had been obtained or verified from the resident or surrogate decision-maker, which RN 1 acknowledged.

In an interview, the DON stated that, prior to installing side rails on the beds of these residents, the facility was supposed to obtain a physician’s order, conduct a side rail utilization assessment, and verify that informed consent had been obtained. The DON explained that the physician’s order was necessary to ensure the physician agreed that installing side rails was appropriate and safe, that the side rail utilization assessment was needed to show other interventions attempted before using side rails, and that verifying informed consent ensured residents and their representatives were aware of safety risks associated with side rails. Review of the facility’s undated policy and procedure titled “Bed Safety and Bed Rails” showed that consideration was to be given to resident safety, medical conditions, comfort, freedom of movement, and input from the resident and family, and that bed frames, mattresses, and bed rails were to be checked for compatibility and size. The policy also specified that residents at higher risk for injury, including bed entrapment, required additional safety measures and that a resident assessment to determine risk of entrapment should include factors such as medical diagnoses, size and weight, sleep habits, medications, acute interventions, underlying conditions, delirium, toileting ability, cognition, communication, mobility, and fall risk. The policy further required that, before using bed rails for any reason, staff inform the resident or representative about benefits and potential hazards and obtain informed consent, including information on assessed medical needs, risks and mitigation, alternatives attempted and their failure, and alternatives considered but not attempted and the reasons.