F0689

D

Failure to Follow Two-Person Assist and Side Rail Orders Resulting in Bed Fall

Bell Gardens, California Survey Completed on 01-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident’s environment was free from accident hazards and that adequate supervision and assistive devices were provided as ordered. The resident had a history of hemiplegia and hemiparesis following a stroke affecting the left side, hypertension, and aphasia, and was documented as severely cognitively impaired. The resident’s MDS dated 12/25/2025 indicated dependence on staff for oral hygiene, toileting, bathing, dressing, personal hygiene, and rolling left and right. The History and Physical dated 10/14/2025 stated the resident did not have the capacity to understand and make decisions, and a Fall Risk Assessment dated 12/25/2025 identified the resident as at risk for falls.

The resident’s care plan for Activities of Daily Living Self-Care Deficit, initiated 10/13/2025, indicated the resident required two staff participation to reposition and turn in bed. A document titled Roll Left and Right Task, dated 12/26/2025 at 8:10 p.m., defined the resident as dependent for rolling, meaning the helper did all the effort or that two or more helpers were required. The DON and RN 1 both stated the resident required a two-person assist in bed mobility and repositioning because the resident was unable to hold herself up or keep herself from rolling over the edge of the bed when on her side. The facility’s Repositioning policy required staff to check the care plan, assignment sheet, or communication system to determine the resident’s specific positioning needs, including the number of staff required.

Despite these documented needs and orders, on 12/26/2025 at approximately 9 p.m., CNA 4 provided incontinence care and repositioned the resident onto her right side alone, without a second staff member and without side rails in place. During the brief change, the resident began to shift and slide, causing the upper portion of her body to roll toward the floor, and CNA 4 assisted the resident to the floor in a controlled manner. CNA 4 stated she had previously repositioned and changed the resident’s diaper alone without issues, did not check the Kardex for the required level of assistance, and acknowledged the resident had no side rails on the bed. Review of the resident’s orders dated 10/14/2025 showed an order to apply bilateral half side rails to enhance bed mobility and repositioning, which were not in place at the time of the incident. The DON stated that precautions were not in place to safely reposition the resident and that the fall could have been prevented if a second person had been present and the ordered side rails had been installed.