F0689

G

Failure to Ensure Safe In‑Bed Care and Timely Fall‑Prevention Measures

Stockton, California Survey Completed on 01-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure safe care and adequate supervision during in‑bed care for a resident, resulting in a fall and fracture. The resident was admitted in 2025 with multiple orthopedic and musculoskeletal conditions, including intervertebral disc degeneration of the lumbar region, a closed right patella fracture, an infection of an internal fixator in the right ankle, and a history of an unspecified fall. A Fall Risk Assessment dated 10/18/25 scored the resident at 25, categorized as a moderate fall risk. The resident’s MDS Section GG, dated 9/22/25, documented a need for substantial/maximum assistance with toileting and hygiene, meaning staff performed more than half the effort and held or lifted the trunk and limbs.

On the morning of 1/23/26, CNA 2 provided incontinence care after finding the resident incontinent of stool in bed. CNA 2 rolled the soiled linens and tucked them under the resident while the resident was on her side. CNA 2 reported that she had one hand on the resident to steady her and one hand on the tucked linen, and then attempted to pull the soiled linen out with one hand but was unable to do so. CNA 2 stated she instructed the resident to hold onto the cabinet or bed frame so that CNA 2 could use both hands to pull the linens. CNA 2 then removed the hand that had been supporting the resident in order to use both hands on the linens. According to CNA 2, the resident indicated it was acceptable for her to let go, and CNA 2 proceeded to pull the linens; at that point, the resident fell from the bed onto the floor on her right side. The resident later reported that she had been holding the privacy curtain when she fell. At the time of the fall, there were no side rails on the bed and no fall mats on either side of the bed.

Following the fall, the resident complained of right arm pain, with documentation of pain at level 7 and painful, limited ROM in the upper extremity. An x‑ray obtained that day showed a horizontal distal humerus fracture without displacement of the right elbow. The IDT Falls Progress Note dated 1/25/26 documented that the resident fell when CNA 2 was turning her and that, per the resident’s statement, she was holding onto the side of the mattress and leaning too much, resulting in loss of balance and a fall. Predisposing factors listed included a history of falls, muscle weakness, gait/balance deficit, poor safety awareness, and overestimation of limits. The same IDT note listed preventive measures such as a low, locked bed and a landing mat on the floor to reduce impact and injury of falls, but the DON later confirmed that a fall mat was not actually in place at the time of the fall and was only placed days later. The DON also confirmed that a physician’s order for quarter side rails for mobility and positioning was dated 1/26/26, with a bed rail assessment and resident consent completed that same day, but the rails were not installed until 1/28/26. The DON acknowledged that once the resident fell, a fall mat should have been placed immediately and that the resident’s injury was preventable. The resident’s treating physician stated he was not aware that only one CNA had provided incontinence care at the time of the fall and stated that there should have been two CNAs providing that care.