F0550

E

Resident Rights Violated When Assist Rails Removed Against Residents’ Wishes

Sonora, California Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to honor resident rights to self-determination, dignity, and participation in care planning when assist rails used for mobility and bed mobility were removed from multiple residents’ beds against their wishes. Five cognitively intact residents, each with documented weakness and mobility impairments, had previously consented to the use of assist rails, had physician orders in place, and in some cases had care plan interventions specifying assist rails for bed mobility and ADL function. Despite this, the facility directed that assist rails be removed, and maintenance staff carried out the removal, including in situations where residents verbally objected.

One resident with anxiety, depression, muscle weakness, and a history of repeated falls had a BIMS score of 15, a signed consent form for assist rails, and a physician order allowing assist rails for bed mobility. This resident reported that the maintenance person removed the assist rails three days prior to the survey despite the resident’s request that they not be removed. The resident stated the rails were used to help turn in bed and to hold onto during incontinence care to feel safe and secure, and since removal, the resident experienced ongoing fear of falling out of bed and feeling scared. Another resident with hemiparesis, hemiplegia, difficulty walking, muscle weakness, and wheelchair dependence, also cognitively intact with a BIMS of 15, had consented to assist rails and had a physician order for their use. After a discharge and return to the facility, this resident found the rails had been removed, reported previously using them to pull up in bed, reposition, and stand and pivot, and stated that repeated requests to staff to have the rails replaced had not been honored, leading to concerns about getting weaker and feeling scared during turning and incontinence care without the rails.

A third cognitively intact resident with muscle weakness, difficulty walking, and lack of coordination had a consent form, a care plan intervention for assist rails for bed mobility, and a physician order permitting assist rails. This resident reported that the rails were removed on a specific date and remained off until the day before the survey, during which time the resident experienced a near fall when trying to go to the bathroom and reported loss of independence, including no longer being able to change their own incontinent briefs and needing two staff for this care, which the resident described as humiliating. A fourth cognitively intact resident with difficulty walking, muscle weakness, depression, anxiety, and obesity had a care plan for assist rails on both sides of the bed for bed mobility, a consent form for bilateral grab/assist/mobility bars, and a physician order for assist rails. Nursing staff interviews confirmed that assist rails had been removed facility-wide, that residents had used them for mobility assistance and turning in bed, and that residents were upset, with one nurse stating a resident was devastated. The maintenance director stated he was directed to remove assist rails from residents who were not “required” to have them and was unsure if nursing staff had explained the removals to residents, acknowledging that some residents had a problem with the removal. The assistant director of nursing stated that residents who wanted to keep rails had been evaluated, had orders, and had care plans, but she was later told to re-evaluate whose rails were “necessary.” These actions conflicted with the facility’s written policy on resident rights, which includes the right to participate in the development and implementation of the person-centered care plan, to sign after significant changes to the plan of care, to a dignified existence and self-determination, to be treated with dignity and respect, to reasonable accommodation of individual needs or preferences, and to make choices about significant aspects of life in the center.