F0689

D

Failure to Supervise High Fall-Risk Resident During Ambulation

Temple City, California Survey Completed on 01-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision and assistance to prevent a fall for a resident assessed as high risk for falls. The resident had diagnoses including cataract, muscle weakness, and right arm pain, and an MDS dated 10/24/2025 documented moderately impaired cognitive skills for daily decision-making. The MDS also indicated the resident required supervision/touching assistance for ambulation (walking 10 feet, 50 feet with two turns, and 150 feet) and setup/cleanup assistance for toileting hygiene, lower body dressing, footwear, and personal hygiene. The resident’s fall risk assessment dated 12/3/2025 identified the resident as high risk for falls. The care plan for fall risk, revised 10/30/2025, directed staff to provide assistance with transferring and locomotion as needed and to educate/remind the resident to request assistance prior to transfer/ambulation. A separate care plan for elopement risk, also revised 10/30/2025, instructed staff to address wandering behavior by walking with the resident and to evaluate the need for additional supervision.

On 12/16/2025, the resident experienced a witnessed fall outside the patio area while entering another unit, during which the resident fell backward and hit his head on the floor. Progress notes from that date at 9:00 AM documented that the resident fell outside the patio area while entering another unit and fell backward while trying to grab his wheelchair. In an interview, the resident stated he had been walking by himself while pushing the wheelchair when he fell outside the unit. A respiratory therapist reported observing the resident using his wheelchair like a walker, losing balance, and falling backward while she was only present to open the door and was not supervising the resident; she confirmed the resident was by himself at the time of the fall. The RN supervisor and QA nurse both confirmed that, based on the MDS and care plan, the resident required supervision/touching assistance when walking, meaning a person should be with the resident to guide and help as needed, and acknowledged that no one was with the resident and he did not have the required assistance at the time he was ambulating and fell. Facility policies on fall management, care planning, and safety of residents required development and implementation of care plans and provision of a safe environment, but the resident was allowed to ambulate without the indicated supervision and assistance when the fall occurred.