LOS ANGELES, CA - A resident at Brier Oak on Sunset nursing home died after falling from an elevated bed while receiving care from a single staff member who failed to follow established safety protocols, according to federal inspection records.
Fatal Fall During Care
The incident occurred on the evening when Certified Nursing Assistant (CNA 1) was providing care to Resident 3, a 252-pound woman with paraplegia, morbid obesity, and generalized muscle weakness. According to facility records, the resident required two-person assistance for all activities of daily living due to her severe physical limitations and cognitive impairments.
CNA 1 elevated the resident's bed to approximately three feet off the ground to provide incontinence care. While attempting to change the resident's brief, the aide positioned herself on one side of the bed and rolled the resident onto her left side. The resident's roommate witnessed the fall, stating she heard it happen around 10 p.m.
During the care procedure, CNA 1 placed the resident's hand on the bed rail but removed her own supporting hand to manage the incontinence brief. At that moment, the resident let go of the handrail and fell face-first to the floor. The resident sustained a 1.5-inch laceration to her left eyebrow and significant blood loss.
Emergency Response and Tragic Outcome
Emergency medical services arrived at 10:10 p.m., approximately 20 minutes after staff discovered the resident on the floor. Paramedics found the resident "laying supine on ground naked with approximately 3-inch laceration to left eyebrow and approximately 1 liter of blood next to her head."
The Los Angeles Fire Department report documented that the resident was found pulseless and not breathing. Although staff initially stated the resident had a Do Not Resuscitate order, it took approximately five minutes to provide documentation. CPR was discontinued once the DNR status was confirmed, and the resident was pronounced dead at 10:21 p.m.
Critical Safety Protocol Failures
Federal inspectors identified multiple safety violations that contributed to this fatal incident. The resident's care plan, developed earlier in the year, specifically required two-person assistance for bed mobility due to her diagnoses of paraplegia and generalized weakness. However, CNA 1 attempted to provide care alone.
Licensed Vocational Nurse (LVN 1) confirmed during interviews that "Resident 3 required two staff or 3 staff depending on how small the staff was, for care." Despite this known requirement, no additional staff member was called to assist during the nighttime care.
Specialized Mattress Safety Ignored
The resident was using a Low Air Loss Mattress (LALM) set to 300 pounds for pressure injury prevention. These specialized mattresses alternate pressure to prevent bedsores but create an unstable surface during patient care. Safety protocols require changing the mattress to "static mode" during care procedures to provide a firm, stable surface.
The mattress manufacturer's guidelines clearly state that static mode should be used "to discontinue alternation therapy for patient transfer, caregiving, comfort, or preference." When in alternating mode, the mattress continuously inflates and deflates different sections, making it unsafe for patient repositioning.
CNA 1 stated during interviews that she "was told not to touch the LALM settings" and had "never had a nurse change the LALM setting when doing care" since being hired. This revealed a dangerous communication breakdown between nursing staff and aides regarding essential safety procedures.
Care Plan Discrepancies Created Danger
Federal inspectors discovered significant discrepancies between the resident's assessment scores and her written care plan. The Minimum Data Set (MDS) assessment indicated the resident was dependent and needed two-person assistance for bed mobility. However, her care plan stated she required only one-person assist.
Registered Nurse (RN 2) acknowledged during inspection interviews that "if MDS was not accurate, the plan of care will also not be accurate" and "it place the resident at risk of improper care." The Director of Nursing confirmed that the care plan did not correlate with the resident's actual needs based on her documented dependencies.
This mismatch between assessment and care planning meant that staff received incorrect guidance about the level of assistance required for safe care. The resident's paraplegia, morbid obesity, and cognitive deficits created a high-risk situation that demanded careful safety protocols.
Medical Consequences of Falls from Height
Falls from elevated surfaces pose extreme danger for nursing home residents, particularly those with multiple medical conditions. When residents fall from beds positioned three feet off the ground, the impact force increases dramatically compared to falls from standard bed height.
For residents with paraplegia, the inability to use lower extremities for protection during falls significantly increases injury risk. The resident's morbid obesity further complicated her ability to break her fall or protect herself from impact. Head injuries from falls at this height often result in severe trauma due to the direct impact with hard flooring surfaces.
Blood loss of one liter, as documented by paramedics, represents a life-threatening emergency. This volume of bleeding indicates severe vascular injury that requires immediate medical intervention. The delay between the fall and emergency response may have contributed to the fatal outcome.
Industry Standards for Safe Patient Handling
Professional nursing standards require comprehensive assessment of patient mobility needs and strict adherence to established care plans. When residents require two-person assistance, facilities must ensure adequate staffing and clear communication protocols.
Specialized mattress systems like LALM devices require specific training for all staff members. The alternating pressure function that prevents bedsores becomes a safety hazard during patient care unless properly managed. Industry best practices mandate that all direct care staff understand when and how to adjust these devices for safe patient handling.
Fall prevention protocols should include bed height management, particularly during care procedures. Elevating beds above necessary working height creates unnecessary fall risks, especially for residents with mobility impairments.
Immediate Jeopardy Declaration
Federal inspectors declared an Immediate Jeopardy situation, the most serious level of violation, indicating that facility practices posed immediate threat to resident health and safety. This designation triggered mandatory corrective action requirements and increased oversight.
The facility submitted a comprehensive removal plan addressing staff training, care plan accuracy, and safety protocol implementation. Corrective actions included reassessing all residents requiring two-person assistance, updating care plans for residents with specialized mattresses, and implementing new audit procedures.
Ongoing Investigation
The California Department of Public Health continues to monitor the facility's compliance with safety standards. The incident highlights critical gaps in nursing home safety protocols and staff training that can have fatal consequences for vulnerable residents.
Families evaluating nursing home care should inquire about staff training protocols, care plan accuracy measures, and safety procedures for residents requiring specialized equipment. Understanding these safety systems can help prevent similar tragedies and ensure appropriate care for loved ones with complex medical needs.
The inspection report notes that the nursing home is disputing the citation, though the factual findings regarding the fall and subsequent death remain documented in federal records.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brier Oak On Sunset from 2024-08-09 including all violations, facility responses, and corrective action plans.
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