F0689

G

Failure to Implement Adequate Fall Prevention and Door Alarm Safety Measures

Torrance, California Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and provide adequate supervision and fall prevention measures for a high‑risk resident, as well as failure to maintain active door alarms. The resident, identified as having a history of falls, impaired balance, unsteady gait, difficulty walking, and end‑stage renal disease, was dependent or required substantial to maximal assistance for most ADLs, including toileting, transfers, and walking. The resident’s assessments and care plans documented high fall risk, fluctuating capacity to understand and make decisions, and a history of repeated falls. Existing fall care plans focused on a clutter‑free environment, call light use, close monitoring, and toileting schedules, but did not include specific device‑based interventions such as bed alarms, landing pads, or other enhanced safety measures.

On one evening, the resident experienced an unwitnessed fall at approximately 9 p.m. after being last seen in the room around 6:30 p.m. CNA and LVN interviews and the change‑of‑condition documentation indicated the resident was found on the floor, with no apparent injuries and unable to explain what happened. Despite this fall and the resident’s known high‑risk status, the care plan titled “Unwitnessed Fall” was not updated to add interventions such as a bed alarm, landing pads, keeping the bed in the lowest position, or increased monitoring. Staff interviews, including from the LVN, RN supervisor, and DON, confirmed that no new fall‑prevention interventions were added after the first fall, and that frequent rounding (e.g., hourly checks) and closer supervision were not implemented. CNA and LVN staff also stated that the resident frequently attempted to get up without assistance and required constant help with toileting, yet monitoring was described as every two hours at best, and not hourly following the change in condition.

Approximately four hours after the first fall, around 1 a.m., the resident sustained a second fall, again while attempting to go to the bathroom, resulting in a one‑inch laceration to the left forehead, skin tears to the left elbow, forearm, and hands, and generalized bruising and scabs noted on hospital evaluation. The facility’s policy on Accidents and Incidents‑Investigating and Reporting required prompt investigation, collection and evaluation of information to determine the cause of falls, and identification of pertinent interventions to prevent subsequent falls, including trying various interventions until falling reduced or stopped. Interviews with nursing staff and the DON confirmed that these policy expectations were not met for this resident, as underlying causes were not fully addressed and additional interventions were not implemented between the first and second falls.

A separate but related deficiency involved the facility’s failure to ensure that the front door and three of four emergency exit doors had active alarms when accessed from inside the building. Observations with the RN supervisor and a CNA showed that the front door could be pushed open without an alarm and that alarms on three exit doors were not activated, including a door used by staff to transport linens. Staff interviews, including with the RN supervisor, CNA, and the Administrator, confirmed that these doors should have been alarmed from the inside as part of the facility’s security plan to address resident elopement risk and interior building security. The facility’s Security Plan policy referenced the use of electronic alarm systems and resident‑specific security needs, including risk for elopement, but the observed lack of active alarms on these doors did not conform to that plan.