F0689

E

Failure to Implement and Monitor Effective Fall-Prevention Measures After Repeated Falls

Sacramento, California Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision and implement effective fall-prevention interventions for a cognitively impaired resident with a known history of falls. The resident was admitted with dementia, schizophrenia, and seizures, was nonverbal or minimally verbal, and required extensive assistance with ADLs, including two-person assistance for dressing, bathing, toileting hygiene, and toilet transfers, and one-person assistance for transfers and standing. An MDS dated 1/6/26 documented severely impaired decision-making and that the resident was rarely or never understood. A physician progress note on the same date described the resident as nonverbal, minimally interactive, lacking capacity for informed consent, and having a history of falls, requiring assistance for ADLs, feeding, and mobility.

On 1/4/26, the resident experienced a fall in the room after staff heard the roommate yell “Man down!” and found the resident on the floor next to the bed with discoloration to the right forehead. The care plan entry for that fall stated there was an actual fall with no injury, which conflicted with the progress note documenting discoloration to the forehead. The DON acknowledged this discrepancy and stated the progress note could be expanded but reported that no staff or residents were interviewed to investigate the fall and no additional steps were taken to identify, monitor, or prevent future falls. The care plan dated 1/4/26 was updated only to include monitoring and reporting for 72 hours for signs and symptoms such as pain, bruises, or changes in mental status, and did not include any new fall-prevention interventions. An IDT fall review dated 1/6/26 listed “sent to hospital for eval” as a new intervention, which contradicted the medical record that did not show a hospital transfer on 1/4/26.

On 1/10/26, the resident had another unwitnessed fall documented in a progress note as having no visible injuries. However, an IDT fall form dated 1/12/26 described a nurse witnessing the resident roll to the right side of the bed, fall out of bed, collide the head with the roommate’s bed, lose consciousness for 20 seconds, and have active bleeding from the right forehead, after which the resident was transferred to the emergency department. Prehospital and ED records from that date documented a one-inch laceration above the right eye and a small right frontal abrasion with wound irrigation and dressing. The IDT fall form dated 1/12/26 listed “fall mats and lower bed” and “transfer to acute” as new interventions, but the care plan did not reflect fall mats, and the fall-prevention interventions added to the care plan on 1/10/26 (anticipating needs, educating the resident about safety, and PT evaluation) were already present in the admission care plan dated 12/31/25. The DON stated the falls on 1/10/26 were reviewed by the IDT after the weekend and that interventions were evaluated when the resident was transferred to the hospital and upon return, but did not identify any other steps taken to identify, monitor, or prevent future falls, and stated the resident had not sustained injuries from the 1/10/26 falls, which conflicted with ED and IDT documentation.

On 1/13/26, the resident sustained another fall in the shared bathroom. Staff interviews indicated that a CNA and an LN responded after hearing the roommate scream for help and found the resident on the bathroom floor, confused and with difficulty communicating. The cognitively intact roommate reported seeing the resident standing in the shared bathroom, then tripping and falling forward, hitting his head on the door, then falling backward and hitting the back of his head, followed by shaking on the floor. EMS documentation recorded that staff reported the roommate had heard a loud bang in the bathroom, found the resident on the floor, and that the resident was on blood thinners with a bump to the back of the head and an old bump above the right eye from a prior fall. Hospital trauma and orthopedic records from the subsequent admission documented an acute distal right clavicle fracture with tenderness over the fracture site and a hospitalization from 1/13/26 to 1/17/26 for a fall with a right clavicle fracture and non–weight-bearing status to the right upper extremity. The care plan revised on 1/13/26 indicated no injuries from the 1/13/26 fall, contradicting the hospital records. The DON stated there were no witnesses to the fall and that she did not investigate further or speak with any staff or residents about the fall. Throughout these events, facility policies on falls and comprehensive assessments, which required ongoing evaluation of causes of falls, documentation of appropriate interventions to prevent future falls, and monitoring and documentation of responses to interventions, were not followed as evidenced by the lack of new, implemented, and consistently documented fall-prevention measures after repeated falls and injuries.