F0689

D

Failure to Implement Fall-Prevention Interventions for High-Risk Resident

San Gabriel, California Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate accident prevention interventions, including use of a bed alarm, monitoring and documentation of sleep patterns, and timely physician notification of insomnia or anxiety, for a resident assessed as at risk for falls. The resident was admitted with dementia, hypertension, and legal blindness, and was identified on a Fall Risk Evaluation as at risk for falls, with intermittent confusion, bedbound/incontinent status, and poor vision. The MDS documented severely impaired cognitive skills for daily decision making, bilateral upper extremity impairment, unilateral lower extremity impairment, and dependence or significant assistance needed for all ADLs, including rolling in bed. The care plan identified the resident as at risk for falls related to confusion, gait/balance problems, poor communication/comprehension, unawareness of safety needs, and restlessness while in bed, and also included a care plan for coronary artery disease with an intervention to monitor and document sleeping patterns, inform the physician of any insomnia or anxiety, and give sedatives as ordered.

Despite these identified risks and care plan directives, the facility did not implement or document monitoring of the resident’s sleep pattern, and there was no sedative order in place. Multiple staff interviews, including with RN 1, LVN 2, and the ADON, confirmed there was no documented evidence that the resident’s sleep pattern had been monitored, even though it was listed as a care plan intervention. Staff also stated that if sleep monitoring was part of the care plan, it should have been ordered and reflected on the MAR so that licensed nurses could document hours of sleep. RN 1 acknowledged that the care plan was not resident-centered and that the intervention to monitor/document sleep pattern and notify the physician of insomnia or anxiety had not been carried out. The DON verified that the intervention to monitor and document sleep pattern was not implemented.

The facility also failed to provide a bed alarm for this resident, despite the resident’s severe cognitive impairment, blindness, restlessness, and inability to use the call light or verbalize needs. LVN 1 stated the resident did not have a bed alarm and should have had an order for one to alert staff when the resident was no longer in a safe position in bed. LVN 2 and the ADON similarly stated that a bed alarm could have helped prevent a fall by alerting staff when pressure was off the bed. Staff interviews described the resident as usually restless at night, not sleeping like other residents, and moving or squirms frequently in bed. On the night of the incident, documentation and interviews indicated the resident was restless, screaming, moaning, and constantly moving in bed from around 1–2 AM, with repositioning and distraction attempts for comfort. At approximately 5:30 AM, the resident was found on the floor on the right side of the bed, face down between the bed and nightstand, with a 2 cm abrasion on the left forehead. The IDT progress notes identified the likely root causes of the fall as severe cognitive impairment, restlessness, and significant physical limitations, and the DON confirmed that the fall care plan did not include a specific intervention to address the resident’s restlessness while in bed and instead contained only a general directive to follow the facility fall protocol.