LOS ANGELES, CA - Federal inspectors found Skyline Healthcare Center violated patient safety regulations by installing bed rails on multiple residents without proper physician orders, safety assessments, or informed consent, according to a June 2024 inspection report.
Three Residents Affected by Improper Bed Rail Use
Inspectors documented three separate cases where the facility improperly used bed rails as restraints, potentially exposing residents to serious safety hazards including entrapment.
Resident 15 was found lying in bed with both upper bed rails raised despite a May 23, 2024 assessment that specifically indicated "side rails/assist bar were not indicated at this time." The resident had contractures, osteomyelitis, and muscle wasting, and was totally dependent for mobility and daily activities.
Resident 74 was observed with the left upper bed rail up, even though a May 30, 2024 assessment determined no bed rails were needed. This resident was ambulatory and had not shown difficulty with bed mobility.
Resident 64 had quarter rails on both sides of the bed head despite a May 13, 2024 assessment concluding that side rails were not indicated. This resident had severe cognitive impairment and required substantial assistance with daily activities.
Missing Critical Safety Requirements
The facility's own registered nurse confirmed during interviews that none of the three residents had physician orders for bed rail use, nor did any have the required informed consent documentation.
"There was no physician order and no informed consent for side rail use," stated Registered Nurse 1 during the inspection. "The side rails should have not been placed for use if the assessment did not indicate the resident needed side rails."
The Director of Nursing acknowledged that "prior to use of bed rails, there should be a physician's order and an informed consent from the resident or their representative and an assessment for its use."
Understanding Bed Rail Entrapment Risks
Bed rails can create serious entrapment hazards when improperly used. The FDA has documented cases where residents have become trapped in the gaps between bed rails and mattresses, potentially leading to injury or death.
Entrapment typically occurs in seven zones around hospital beds: between the rail and mattress, under the rail at the foot or head of the bed, between rail segments, between the headboard and mattress, and between the footboard and mattress. These spaces can trap a resident's head, neck, or torso.
The risk is particularly high for residents with cognitive impairment, mobility limitations, or certain medical conditions - characteristics present in all three affected residents at Skyline Healthcare Center.
Regulatory Requirements and Best Practices
Federal regulations require nursing homes to obtain physician orders before installing bed rails because they are considered restraints when they prevent residents from freely exiting their beds. Facilities must also conduct proper assessments to determine if bed rails are medically necessary and obtain informed consent from residents or their representatives.
The facility's own policy, last reviewed April 4, 2024, clearly states that bed rails "cannot be used for staff convenience or as discipline" and requires detailed physician orders before any restraints can be used. The policy also mandates that physicians obtain informed consent and that licensed nurses initiate care plans around bed rail use.
Proper bed rail assessment should consider the resident's mobility level, cognitive status, fall risk, and ability to understand instructions. Alternative safety measures like floor mats, bed alarms, or increased supervision should be considered before resorting to bed rails.
Additional Staffing and Medication Violations
The inspection also revealed staffing oversight failures, with the facility missing required annual performance evaluations for at least one certified nursing assistant. Performance evaluations are critical for identifying competency gaps and ensuring staff can safely care for residents.
Medication management problems also emerged, with one resident missing a scheduled dose of apixaban, a blood-thinning medication used to prevent dangerous blood clots. The medication was unavailable because staff failed to reorder it timely, despite facility policies requiring reorders when a four-day supply remains.
The resident was prescribed apixaban for deep vein thrombosis management. Missing doses can potentially lead to blood clot formation, which could travel to vital organs and cause heart attacks or strokes.
Medication Error Rate Exceeds Standards
Inspectors calculated an overall medication error rate of 12.5% during their observations - significantly higher than the 5% threshold established by federal standards. This rate was based on four medication errors out of 32 total opportunities across five residents.
The errors included the missed apixaban dose, failure to administer calcium supplements as ordered, and improper crushing of extended-release medications that should not be altered according to manufacturer guidelines.
Facility Response and Corrective Actions
The facility's Director of Nursing acknowledged that bed rail assessments indicating no need for rails "should have been followed and no bed rails should have been applied." The director stated that applying bed rails when assessments indicate they're unnecessary "predisposes the resident to harm such as entrapment."
Federal regulations require nursing homes to submit formal plans of correction addressing identified deficiencies. These plans must detail specific steps to resolve violations and prevent recurrence.
The violations at Skyline Healthcare Center highlight the importance of following established protocols for resident safety equipment and maintaining proper oversight of clinical practices. Bed rails, while sometimes medically necessary, require careful evaluation and monitoring to ensure they enhance rather than compromise resident safety.
For families with loved ones in nursing homes, these findings underscore the value of understanding facility policies around restraints and asking questions about safety measures being used in their relative's care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Skyline Healthcare Center - La from 2024-06-13 including all violations, facility responses, and corrective action plans.
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