F0689

D

Failure to Implement Individualized Fall-Prevention Monitoring for High-Risk Resident

Glendale, California Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and accident prevention for a high fall-risk resident in accordance with its own policies, including the Falling Star Program and Safety Supervision of Residents. The resident was admitted with unsteadiness on feet, a history of falls, osteoarthritis, and cognitive decline, and was later assessed as having moderately impaired cognition and requiring partial to moderate assistance with ADLs. A Fall Risk Collection record dated 12/15/2025 scored the resident at 14, indicating high fall risk and a need for increased supervision. Despite this, the resident’s care plans primarily focused on the use of a bed and wheelchair pad alarm and a self-release soft belt, with no individualized or specific interventions describing the type and frequency of monitoring or supervision required.

The resident experienced an unwitnessed fall on 12/15/2025 when the bed pad alarm sounded and nursing staff found the resident on the floor next to the bed with no apparent injury. Subsequent care plan updates for falls and actual fall events continued to emphasize the use of pad alarms and a soft belt but did not add new, individualized interventions or specify additional monitoring or supervision. The facility’s Fall Management and Falling Star Program policies required staff to identify interventions related to specific risks, implement additional or different interventions if falls recurred, and determine the type and frequency of supervision based on assessed needs. However, the care plans remained general, and there was no documentation identifying specific monitoring requirements or scheduled safety rounds as outlined in the Falling Star Program policy.

On 1/25/2026, the resident sustained a second unwitnessed fall when a CNA heard the bed pad alarm and found the resident lying on the floor on her back. Initial assessment documented no visible injuries, but the resident complained of left leg pain and was medicated with Tylenol. Later that day, the resident reported increased left leg pain rated 8/10, and nursing staff observed the left leg slightly externally rotated, leading to transfer to a general acute care hospital where imaging revealed a left femur fracture requiring ORIF surgery. Interviews with nursing staff and the DON confirmed that the resident was a high fall risk, that residents on the Falling Star Program were supposed to receive closer monitoring, and that there was no monitoring conducted between 11 PM and 7 AM. The DON acknowledged that the resident should have been on the Falling Star Program since admission, that care plan interventions were general and not specific to the type and frequency of monitoring, and that monitoring was only visual and not documented, demonstrating a failure to implement and document required supervision and safety measures.

Additionally, although the resident was identified as high risk and on the Falling Star Program after multiple falls, there was no indication in the care plan of specific monitoring interventions such as defined observation intervals or documented safety rounds. The facility’s policies required ongoing identification of safety risks and environmental hazards and adjustment of supervision based on changes in the resident’s condition or environment, but the record did not show such individualized adjustments. After the resident’s return from the hospital with a left femur fracture and ORIF, observations showed that there was no fall mat at the bedside, and staff interviews confirmed that the resident did not have a fall mat. The DON stated that a fall mat was not used due to concern it would be an environmental hazard for the resident, but this did not change the fact that the facility had not clearly determined or documented the type and frequency of supervision required for this high-risk resident, nor had it implemented the full scope of monitoring and safety measures contemplated by its own policies.