F0689

G

Failure to Implement Bedside Safety Devices and Appropriate Assistance on LAL Mattress Resulting in Resident Fall and Head Injury

Bakersfield, California Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent accidents for one resident with significant cognitive and physical impairments. The resident had diagnoses including traumatic cerebral hemorrhage, dementia, bipolar disorder, chronic pain, contractures, and abnormal posture, and was assessed as dependent for toileting hygiene and rolling in bed. An MDS showed the resident was unable to complete the BIMS interview and had both short- and long‑term memory problems, as well as impairments of both lower extremities. Despite these conditions, the facility did not consistently implement ordered and care‑planned safety interventions.

A physician’s order dated 7/13/2020 directed that the resident "may have bilateral landing mats to sides of bed" and required an LN to check placement every shift, day and night. The resident’s care plan, under the focus of risk for pressure injury development, also included an intervention for bilateral landing mats to the sides of the bed. However, on observation in the resident’s room, no bilateral landing mats were present at the bedside. The DON confirmed that there was no documentation on the TAR or MAR for January that LNs had checked landing mat placement each shift, and stated that the mats were not in place at the time of the resident’s fall and that the physician’s order and care plan were not followed. CNA 2, who was providing toileting care at the time of the fall, also stated there were no bilateral landing mats at the bedside when the resident fell.

The facility also failed to update and implement the care plan to reflect the need for two‑person assistance during toileting hygiene for a dependent resident on a low air loss (LAL) mattress. The resident’s care plan for risk of pressure injury indicated use of an LAL mattress for wound management and preventive measures, and the physician’s order and MAR documented that the LAL mattress was in place, functioning, and at correct settings on every shift up to the date of the fall. The care plans addressing contractures, limited ROM, history of falls, and functional loss did not specify two‑person assistance for ADL care. CNA 2 reported she had been told in report that the resident was a one‑person assist and described rolling the resident during toileting care when the resident tensed up and slid off the edge of the bed. CNA 3 stated the resident was totally dependent for ADLs and was always a two‑person assist, and that residents on LAL mattresses were always two‑person assists. The DSD stated she had educated CNAs that residents on LAL mattresses required two‑person assistance, one staff on each side of the bed, and that the LAL mattress was risky because it could move during care, and that the care plan should have been updated to indicate two‑person assistance. The facility did not have specific policies for following physician orders or for care of dependent residents on LAL mattresses, despite a general safety and supervision policy requiring identification of hazards, communication of interventions, assignment of responsibility, training, implementation, and monitoring of safety interventions.

These failures culminated in a witnessed fall on the evening of 1/25/26 while CNA 2 was providing toileting care. According to the SBAR/COC, the resident was on a fully inflated LAL mattress with no fall mats present and was found lying on his back next to the bed with blood dripping from the back of his head. The narrative indicated that when the CNA turned the resident, his lower extremities shifted toward the edge of the bed; as the CNA moved to the other side to reposition his legs, he fell from the bed. The resident sustained a laceration to the back of the head and was transferred to an acute hospital, where a CT scan showed a trace subarachnoid hemorrhage in the right frontal and, to a lesser degree, parietal lobes. The resident was admitted to the hospital for three days and later readmitted to the facility with a diagnosis of traumatic subarachnoid hemorrhage status post fall.