SYLMAR, CA - Astoria Nursing and Rehab Center failed to ensure proper fall prevention protocols for a resident with spinal fractures and a history of falls, with staff admitting the required bed alarm system was disconnected and non-functional during a state inspection.
Disconnected Safety Equipment Discovered During Inspection
State inspectors conducting a complaint investigation at Astoria Nursing and Rehab Center on April 29, 2025, discovered serious lapses in fall prevention protocols for a vulnerable resident. The resident, admitted just seven days earlier on April 22 with unspecified fractures of the ninth and tenth thoracic vertebrae and a history of falls, was found to have a non-functional bed alarm system that was supposed to alert staff when the resident attempted to get up unassisted.
During the inspection, surveyors observed the resident raising her buttocks and waist from her bed with no alarm sounding. When questioned, the resident stated "she had a bed alarm, but it was off today and was not working." The facility's own staff confirmed the safety failure, with the Licensed Vocational Nurse stating the resident "was not on bed alarm" and a Certified Nursing Assistant reporting the resident "had no bed alarm."
The Director of Staff Development later demonstrated that the sensor wire was completely disconnected from the bed alarm machine, explaining why no alerts were being generated when the resident moved. Only when the wire was reconnected during the inspection did the alarm system begin functioning properly, with a green light activating and beeping sounds occurring.
Medical Significance of Fall Prevention Failures
Thoracic vertebrae fractures, particularly in the ninth and tenth vertebrae located in the middle back region, create significant stability issues and pain that can affect a person's balance and mobility. Residents with spinal fractures face dramatically increased fall risk due to altered posture, reduced core strength, and potential movement limitations while healing occurs.
The combination of spinal fractures, dementia, and previous fall history creates a compound risk profile requiring heightened safety measures. Falls in residents with existing spinal injuries can result in additional fractures, spinal cord damage, or other serious complications that may permanently affect mobility and quality of life. Bed alarm systems serve as a critical early warning system, allowing staff to provide assistance before a resident attempts to ambulate independently.
According to established medical protocols, residents with this risk profile should have multiple layers of fall prevention interventions, including functioning alarm systems, regular safety checks, and staff education about the resident's specific vulnerabilities.
Staff Acknowledge Safety Protocol Failures
The facility's own nursing staff recognized the severity of the oversight during inspector interviews. The Licensed Vocational Nurse admitted "he should have checked and made sure that Resident 1's bed alarm was turned on and functioning," emphasizing that care plans guide nurses in managing residents safely to achieve their goals and ensure their safety.
The Director of Staff Development confirmed that "CNAs, LVNs and nurses are responsible for making sure bed alarms are functioning for residents to prevent falls." This acknowledgment highlights that multiple staff members failed to fulfill their basic safety responsibilities.
The facility's care plan, developed just one day after the resident's fall incident on April 23, specifically called for bed alarm use while the resident was in bed. The interdisciplinary team had met with family members who agreed to the bed alarm intervention, yet the system remained non-functional six days later during the inspection.
Care Planning Requirements Not Met
Beyond the equipment failure, inspectors identified that staff failed to accurately assess the resident's fall risk following the April 23 incident. Proper fall risk assessments are essential for developing appropriate interventions and adjusting care plans based on changing conditions.
The facility's own policy on comprehensive care planning requires that interventions address underlying sources of problem areas through careful data gathering and complex clinical decision-making involving multiple disciplines. The Director of Nursing confirmed that care plans serve as guides for rendering necessary care and that bed alarms were specifically intended as fall prevention interventions.
When care plan interventions are not properly implemented or monitored, residents lose critical safety protections designed to prevent additional injuries and complications.
Additional Issues Identified
The inspection also documented that the facility failed to ensure the nursing home area was free from accident hazards and failed to provide adequate supervision to prevent accidents. These violations were classified as having minimal harm or potential for actual harm, affecting few residents.
The combined failures represent a breakdown in the facility's safety systems at multiple levels, from equipment maintenance and staff oversight to care plan implementation and risk assessment protocols. Such systematic failures can potentially place vulnerable residents at risk for further injury, falls, and accidents, particularly those with existing medical conditions that increase their fall risk.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Astoria Nursing and Rehab Center from 2025-04-29 including all violations, facility responses, and corrective action plans.
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