F0689

G

Failure to Provide Required 1:1 Feeding Assistance and Fall Supervision for High-Risk Resident

El Cajon, California Survey Completed on 02-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to prevent accidents and provide adequate supervision and assistance for a high fall-risk resident with severe cognitive impairment and dysphagia. The resident was admitted with difficulty walking, muscle weakness, a history of falls, an Intellectual Developmental Disability, and dysphagia, and was documented as having decreased safety judgment and severe cognitive deficits. The resident’s MDS identified them as a fall risk with prior falls, and the admission fall risk assessment scored the resident as high risk. The nutritional care plan and speech evaluation specified that the resident required 1:1 feeding assistance due to severe swallowing impairment and aspiration risk, and the resident’s name appeared on the facility’s feeding list. Despite these assessments and care plan directives, staff left the resident alone with a meal tray and did not provide the required feeding assistance or supervision.

On the day of the incident, a CNA reported seeing the resident independently wheeling in the hallway and provided a meal tray, observing the resident eat independently while seated in a wheelchair in the hallway without supervision until approximately 8 p.m. The CNA stated she was not informed that the resident was a fall risk and did not request another staff member to supervise the resident when she left the area to use the restroom. Other CNAs on the unit also reported they were not informed that the resident was a fall risk, although they observed the resident as confused, not fully oriented, and unable to reliably use the call light. One CNA described the resident as requiring maximum assistance for sit-to-stand and transfers, being wobbly and unstable, and needing prompt staff response to prevent unsafe attempts to stand. Another CNA reported that from admission, the resident frequently sat on the edge of the bed, attempted to stand or ambulate without assistance, had difficulty understanding how to use the call light, and was known to be a fall risk, and that these concerns had been reported to licensed nurses.

Licensed nursing staff and leadership interviews further showed that the resident’s fall risk and supervision needs were not adequately assessed, care-planned, or communicated. The supervising nurse on duty acknowledged that the resident was a high fall risk who required close supervision and should have been on 1:1 supervision for safety, but there were no orders or care plan for 1:1 supervision. The nurse documented that the medication nurse had instructed CNAs to perform visual inspections every 30 minutes and to keep the resident under continuous supervision, including remaining in the room if the resident was alone, but this level of supervision was not consistently implemented. Another nurse stated she was not aware the resident was a fall risk prior to the incident, although she recognized that the resident’s IDD, confusion, and communication deficits warranted considering the resident a safety and fall risk. The Director of Staff Development and DON both stated that the resident’s fall risk care plan, which included generic interventions such as educating the resident to call for assistance and keeping the call light within reach, was not individualized to the resident’s cognitive and safety needs and did not effectively reduce fall risk for a resident who could not comprehend or appropriately use the call light.

The incident culminated when staff found the resident lying face down on the floor in the room with a bleeding forehead laceration, unresponsive, and with agonal or irregular respirations. Staff applied oxygen via a non-rebreather mask, stabilized the cervical spine, and called emergency services. Hospital records documented that the resident sustained an L4 compression fracture with 30% height loss, required intubation, was transferred to the ICU, and experienced seizure activity. The hospital discharge summary indicated diagnoses including seizure disorder and dysphagia and stated it was presumed the resident suffered arrest from acute respiratory failure in the setting of recurrent aspiration, with MRI findings consistent with recent seizure activity. The records also showed that the resident had no documented history of seizure activity or feeding tube dependence prior to this facility-to-hospital transfer. The facility’s own policies on comprehensive person-centered care plans and managing falls and fall risk required individualized interventions based on assessment, but the resident’s care plan and supervision practices did not reflect the resident’s identified high fall risk, cognitive impairment, and need for 1:1 feeding assistance and close supervision.