LOS ANGELES, CA - Federal inspectors documented serious safety violations at Los Feliz Healthcare & Wellness Center after finding the facility used bed rails on vulnerable residents without completing required safety assessments, obtaining physician orders, or securing informed consent from residents or their families.
Unauthorized Bed Rail Use Discovered During Inspection
During a June 2024 inspection, surveyors found two residents with both upper bed rails raised despite the absence of proper authorization and safety protocols. The violations occurred with residents identified as high-risk for falls who had documented mobility issues and medical conditions requiring careful monitoring.
Inspectors discovered Resident 118 had both upper bed rails up when they entered the room with facility nursing staff on June 25, 2024. The resident had been admitted in May 2024 following surgical amputation of the right foot's fifth digit, with additional diagnoses including muscle weakness and unsteadiness. Medical records indicated this resident was classified as high-risk for falls.
When nursing staff reviewed the resident's medical records with surveyors, they acknowledged the facility had no physician order authorizing bed rail use. Additionally, the resident's bed rail assessment contained contradictory recommendations - simultaneously indicating that side rails were both "indicated" and "not indicated" for the resident. No documentation existed showing the resident or their representative had been informed about the risks and benefits of bed rail use before the rails were installed.
The same day, inspectors found identical violations in the room of Resident 378, who had been admitted just days earlier on June 18, 2024, with diagnoses including hepatic encephalopathy, seizures, and muscle weakness. This resident also had both upper bed rails raised without any physician order, without any bed rail assessment on file, and without documented informed consent or education provided to the resident or their representative.
Understanding Bed Rail Entrapment Dangers
Bed rails present documented risks that require careful assessment before use. The U.S. Food and Drug Administration released specific guidelines in March 2006 addressing hospital bed entrapment hazards after numerous incidents resulted in serious injuries and deaths.
Entrapment occurs when a resident's body or body parts become caught in the spaces between bed rails and the mattress, between the bed rails themselves, or between the rails and the bed frame. The FDA guidance document identifies seven distinct zones where entrapment can occur within the bed system.
When bed rails are used without proper fit assessment between the mattress and rail system, gaps can form that are large enough to trap a resident's head, neck, chest, or limbs. Residents who are confused, restless, or attempting to exit the bed are at heightened risk. Those with conditions affecting cognition or causing involuntary movements face particular danger.
The facility's own bed frame owner's manual, last revised in April 2018, explicitly warns that "patient entrapment with assist rail may cause injury or death." The manual states that mattresses must fit bed frames and assist rails snugly to prevent entrapment, and emphasizes that accurate assessment of each resident and monitoring of equipment use are required to prevent these incidents.
Medical Risks Associated with Improper Bed Rail Use
Bed rail-related injuries can be severe. Strangulation and asphyxiation represent the most critical risks when residents become trapped between rails or between the rail and mattress. These incidents can occur rapidly, particularly during nighttime hours when monitoring may be less frequent.
Beyond entrapment, bed rails can actually increase fall risks for residents who are capable of getting out of bed independently. When residents attempt to climb over raised rails rather than going around them, they fall from a greater height and may become entangled in the rails during the fall, resulting in more serious injuries than would have occurred without the rails present.
Skin injuries including bruising, cuts, and scrapes occur when residents contact the hard metal or plastic rail surfaces. For residents with fragile skin or those taking blood-thinning medications, even minor contact can result in significant bruising or open wounds.
The psychological impact must also be considered. Bed rails can induce feelings of being trapped or restrained, potentially increasing agitation in residents with dementia or cognitive impairment. This agitation may lead residents to struggle against the rails, further increasing injury risk.
Required Safety Protocols the Facility Failed to Follow
The facility's own policy, last reviewed in May 2024, establishes clear requirements before bed rails can be used. The interdisciplinary team's Restraint Reduction Committee must determine whether a resident should have bed rails based on an individual assessment that includes entrapment risk evaluation.
Federal regulations define physical restraints as any device attached or adjacent to a resident's body that the individual cannot easily remove and that restricts freedom of movement or normal access to one's body. This definition is based on the functional status of the resident, not the device itself. Therefore, bed rails can constitute restraints depending on how they affect each individual resident.
Before placing side rails on any bed, facilities must obtain informed consent when the rail meets the definition of a physical restraint, even when it is also used as an enabler to assist with bed mobility. The space between the mattress and side rails and other potential entrapment zones must be assessed to reduce entrapment risk, with assessments conducted upon admission when side rails are required, after admission if side rails become necessary, or when a mattress is replaced.
Licensed nurses must maintain side rail evaluation documentation in each resident's medical record and develop a care plan reflecting that assessment. These requirements exist to ensure resident safety and prevent the serious injuries associated with improper bed rail use.
Nursing Staff Acknowledge Protocol Failures
When interviewed during the inspection, nursing leadership acknowledged the facility's failures. The Registered Nurse working on the unit stated that prior to installing bed rails, there should be a physician order, a risk for entrapment assessment, informed consent from the resident or representative, and documentation that the resident or representative were educated on the risks and benefits of bed rail use to prevent injuries.
The Director of Nursing similarly confirmed that before installing bed rails, the facility should complete an entrapment risk assessment, obtain a physician order, and secure informed consent from the resident or their representative to ensure resident safety.
Additional Medication Management Violations
The same inspection revealed significant pharmaceutical service violations related to controlled substance accountability and medication disposal documentation.
Inspectors found discrepancies between narcotic accountability logs and actual medication counts in medication carts. For Resident 63, one dose of hydrocodone with acetaminophen was missing from the medication bubble pack compared to the count indicated on the narcotic accountability log. Similarly, one dose of pregabalin was unaccounted for in Resident 226's medication supply, and one dose of oxycodone with acetaminophen was missing for Resident 12.
In each case, the licensed nurse administering medications acknowledged administering the doses but failing to immediately document the administration on the accountability log as required by facility policy. This practice creates opportunities for controlled substance diversion and increases the risk that residents could experience medication errors through underdosing or overdosing.
Inspectors also found that medication disposal logs had not been consistently maintained across all three medication rooms in the facility. One medication room had no disposal documentation at all, while two others had not documented medication disposals for extended periods despite frequent medication changes, discontinuations, and resident discharges that would require disposal.
The Director of Nursing acknowledged that licensed nurses had failed to document medication dispositions on the required logs, potentially due to lack of education. Without proper documentation and accountability for disposed medications, opportunities for diversion increase.
Facility Response and Oversight
Federal regulations require nursing facilities to ensure each resident's environment remains as safe and homelike as possible. Equipment used in resident care must be properly assessed, authorized by physicians when appropriate, and used according to manufacturer specifications and professional standards.
The facility is required to submit a plan of correction addressing how it will ensure bed rails are only used with proper physician orders, completed safety assessments, informed consent, and entrapment risk evaluations. The plan must also address how the facility will ensure controlled substance accountability and medication disposal documentation are maintained according to established policies and procedures.
Los Feliz Healthcare & Wellness Center is located at 3002 Rowena Avenue in Los Angeles. The inspection was completed on June 28, 2024, by the Centers for Medicare & Medicaid Services. The facility received citations for minimal harm or potential for actual harm affecting some residents.
For complete details about the violations found during this inspection, the full federal inspection report is available through the Medicare.gov Nursing Home Compare website.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Los Feliz Healthcare & Wellness Center, Lp from 2024-06-28 including all violations, facility responses, and corrective action plans.
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