F0700

D

Failure to Assess, Obtain Consent, and Timely Implement Physician-Ordered Bed Rails for a High-Fall-Risk Resident

Torrance, California Survey Completed on 03-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to complete required assessments, obtain informed consent, and timely implement physician-ordered bed rails for a resident identified as a high fall risk. The resident was admitted with dementia, multiple rib fractures, and a history of falls. A History & Physical dated 9/28/2025 documented that the resident lacked capacity to understand and make decisions. The care plan dated 1/13/2026 identified confusion and decreased safety awareness secondary to dementia, with goals for the resident to be free of falls and return to previous activity level, and interventions including cueing for safety and education on ambulation and transfer techniques. A nursing evaluation dated 2/12/2026 documented fall risk factors including a history of falls in the last six months, disorientation/confusion, poor safety judgment, and impaired balance. An MDS dated 2/20/2025 indicated severely impaired cognition and a need for substantial/maximal assistance with toileting, bathing, and showering.

On 2/20/2026, a change of condition note documented that the resident was found lying on her back at the end of the bed, reporting that she hit her left ribs and back, with pain rated 4/10 and pain medication administered. An order summary dated 2/23/2026 showed a physician’s order for side rails with fall precautions. Despite this order, a subsequent change of condition on 2/27/2026 recorded that the resident was found sitting on the floor near the doorway after attempting to get up without assistance. An IDT care conference note on 2/27/2026 documented that the resident had a recent fall on 2/20/2026 resulting in a rib fracture and another fall on 2/27/2026, and that the resident had decreased safety awareness and attempted to ambulate independently. On 3/1/2026, an x-ray of the left tibia and fibula showed a possible nondisplaced lateral malleolus fracture of uncertain chronicity. On 3/6/2026, surveyors observed bed rails present on both sides at the head of the bed, but no floor mats at the bedside, and the resident was reported to have been admitted to an acute care hospital.

Staff interviews and record reviews showed that the facility did not follow its own process and policies for bed rail use. A CNA stated the resident was a fall risk and did not have bed rails installed until after hospital admission. An LVN reported that the resident’s family member had repeatedly requested bed rails since the initial fall on 2/20/2026, that staff had asked for the necessary paperwork, and that she did not know why bed rails were not installed after the 2/20/2026 fall or after the 2/23/2026 physician order. The LVN described the facility’s process as requiring a bed rail assessment, a physician’s order, and informed consent after education on risks, benefits, and alternatives, with immediate installation once consent and order were obtained, and physician notification if there was any delay; she confirmed these steps were not completed in a timely manner and could not explain the delay. The RN supervisor similarly stated that the process required a bed rail assessment, physician order, and consent prior to implementation, and that bed rails should be installed without delay and the physician notified of any delay, but could not explain why side rails were not installed until 3/2/2026. The DON stated the family had requested bed rails since the initial fall, that the resident was a fall risk due to dementia and prior falls, and that additional interventions such as a bed alarm and bed rails should have been implemented; she stated policy required a bed rail assessment, physician order, and consent, and that bed rails should be installed within 24 hours, but maintenance was not contacted until 3/2/2026. The maintenance director confirmed he first learned of the need for bed rails on 3/2/2026 and installed them that day. Review of facility policies on falls, restraints, and bed rails showed requirements for pre-restraint assessment, identification of interventions to prevent subsequent falls, and assessment-based decisions regarding bed rail use, which were not carried out for this resident prior to bed rail installation.