F0689

D

Failure to Implement Ordered Bed Rails and Fall-Prevention Measures for High-Risk Resident

Torrance, California Survey Completed on 03-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement and follow fall-prevention measures, including timely installation of ordered bed rails, for a resident with severe cognitive impairment and a high fall risk. The resident was admitted with dementia, multiple rib fractures, a history of falls, and was documented as lacking capacity to understand and make decisions. The care plan identified confusion and decreased safety awareness related to dementia, with goals for the resident to remain free of falls and return to a previous level of activity. Interventions listed included cueing for safety and educating the resident and representative on proper ambulation and transfer techniques. Nursing documentation and the MDS showed the resident had multiple fall risk factors, including a history of falls in the last six months, disorientation/confusion, poor safety judgment, impaired balance, and a need for substantial/maximal assistance with toileting, bathing, and showering.

On one date in February, a change of condition note documented that the resident was found lying on her back at the end of the bed, reporting that she had hit her left ribs and back and was experiencing pain, for which pain medication was given. A physician’s order for side rails with fall precautions was entered a few days later. A PT evaluation indicated the resident required moderate assistance to ambulate 10 feet with a two-wheeled walker. Subsequently, another change of condition note indicated the resident was found sitting on the floor near her doorway after attempting to get up without assistance. An IDT care conference note recorded that the resident had a recent fall resulting in a rib fracture, as well as another fall, and that the resident had decreased safety awareness and attempted to ambulate independently. During one of these incidents, a CNA placed the resident on a shower chair and briefly left to gather supplies, returning to find the resident on the floor. Interventions noted at that time included cueing for safety and placing bilateral mats at the bedside.

Despite the physician’s order for bed rails and the resident’s repeated falls, interviews and record reviews showed that bed rails and other fall-prevention interventions were not implemented in a timely manner. A CNA stated the resident was dependent in ADLs, used a wheelchair, was considered a fall risk, and did not have bed rails installed until after the resident was admitted to the hospital. The CNA and LVN both indicated that residents at fall risk should have interventions such as low beds, floor mats, side rails, bed alarms, and frequent monitoring, and the LVN confirmed that the resident’s family member had repeatedly requested bed rails since the initial fall. The LVN reported witnessing the resident fall from the bed to the floor on a later date, noting that at that time the resident had no floor mats, bed rails, or bed alarm, and that no new interventions were implemented after that incident. The RN supervisor and DON both acknowledged that a physician’s order for bed rails with fall precautions existed, that bed rails should be installed without delay after assessment, order, and consent, and that no new interventions or physician orders were implemented following the resident’s subsequent falls. The maintenance director stated he was first informed to install the bed rails at a stand-up meeting in early March, and installed them that same day. The facility’s policies on Falls-Clinical Protocol and Bed Rails required staff and physicians to identify and implement interventions to prevent subsequent falls and address the risks of clinically significant consequences of falling, but these were not followed for this resident, who ultimately sustained a possible nondisplaced lateral malleolus fracture of uncertain chronicity and was transferred to a general acute care hospital.