F0689

G

Failure to Maintain Safe Bed Position and Adequate Supervision Resulting in Fall and Fractures

Rio Rancho, New Mexico Survey Completed on 02-11-2026

Penalty

Fine: $17,215

Summary

The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision to prevent accidents when a resident’s bed was left in the highest position during care, resulting in a fall. The resident had an admission date of 01/23/23 and a care plan that identified impaired physical functioning and a risk for falls related to a left above-knee amputation, with interventions including two-person substantial/max assist for ADLs and use of a Hoyer lift with two-person assist for transfers. During care on 10/08/25, a CNA provided care alone, asked the resident to hold onto the bedrails during repositioning while the bed was in the highest position, and the resident fell to the floor.

Following the fall, nursing progress notes documented that the resident reported pain to the lower back, right leg/hip, and left arm, and the practitioner was notified with orders for topical analgesic, Oxycodone, labs, and X‑rays. Over the next several days, multiple notes described the resident’s ongoing and severe pain, including 10/10 back and knee pain, moaning in pain during care, increased right knee pain, right foot edema and bruising, and a large bruise on the left hand. Physical therapy notes indicated the resident reported 10/10 back pain, aching pain to the right side of the head, and later right leg pain with tenderness from the right hip to the toes, with a noted decline in mobility and increased fall risk. Provider notes documented inconsistent pain reporting, screaming, nonspecific pain, and the use of pain medications including a muscle relaxer and low-dose Oxycodone.

The DON stated that the resident was not sent to the ER immediately because the resident did not report a head injury, although back pain was reported, and that initial X‑rays of the lower back and right distal femur were read as negative. Due to persistent knee pain, a second X‑ray was ordered and completed, and results received on 10/15/25 showed a right femur fracture, after which the resident was transferred to the hospital. Hospital records confirmed a right distal femur fracture requiring retrograde nail fixation and lumbar compression fractures. The DON acknowledged that the resident’s inconsistent pain reporting contributed to a delayed transfer to the ER and stated that the bed should not have been in the highest position during care. The NP confirmed awareness of the resident’s report of 10/10 pain after the fall and that the resident was sent to the hospital after a second X‑ray identified the femur fracture.