F0558

D

Failure to Provide Recommended Bed Canes to Support Resident Mobility

Chico, California Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The facility failed to reasonably accommodate a resident’s assessed need for bed canes, which had been recommended to support mobility and independence. The resident was admitted with Parkinson’s disease, essential tremor, and muscle weakness, and the admission MDS showed limited function of both legs, a need for touching assistance to roll in bed, and moderate assistance to sit up in bed. The care plan identified the resident as at risk for decline in ADLs and mobility and directed staff to encourage participation in ADLs to promote independence. On admission, a Bed Rail and Entrapment Risk Observation/Assessment was completed and recommended bed canes due to mobility limitations. Despite this, observations on multiple dates showed the resident’s bed had no bed canes or bed rails.

Staff interviews and record reviews confirmed that the resident remained without the recommended bed canes and was dependent on staff for bed mobility. The resident reported needing bed rails/bed canes to pull themselves around in bed and stated they were quite dependent on staff for bed mobility without them. During care, when a CNA asked the resident to roll in bed, the resident stated they could not because there was nothing to hold on to, and the CNA had to assist the resident to roll. The DON and nursing staff confirmed that the assessment recommending bed canes was completed on admission, but a work order for bed canes was not entered until 18 days later, and the bed still did not have bed canes. The Maintenance Director and DON stated the resident’s bed did not accommodate bed canes and there was no compatible bed available because the facility was at maximum capacity, resulting in the resident not receiving the recommended assistive device.