F0689

D

Failure to Follow Fall-Risk Care Plan, CNA Assignment, and Safety Orders Resulting in Unwitnessed Fall

Los Angeles, California Survey Completed on 02-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow an identified fall-risk and incontinence care plan and physician orders for a resident with multiple risk factors, resulting in an unwitnessed fall and prolonged time on the floor. The resident was admitted with incontinence, impaired mobility, and osteoarthritis, and an MDS dated 12/31/2025 showed intact cognition but a need for partial assistance with toileting and transfers, and supervision for multiple ADLs. Care plans initiated in March 2025 identified the resident as at risk for falls related to incontinence and unawareness of safety needs, with interventions including placing floor mats for safety, keeping the bed in the lowest position, anticipating and meeting needs, promptly responding to requests for assistance, and checking the resident every two hours to assist with toileting and provide pericare after each incontinent episode. A fall risk evaluation dated 1/6/2026 identified the resident as a high fall risk requiring assistive devices and taking 1–2 medications that increased fall risk.

On the night shift spanning 1/9/2026 to 1/10/2026 (11 PM–7 AM), the CNA assignment sheet contained an error in that no CNA was assigned to this resident, despite the resident’s identified needs for assistance and supervision. CNA staff later reported that when asked to provide care to the resident at approximately 6:20 AM, they reviewed the CNA assignment sheets for 1/9/2026 and 1/10/2026 and confirmed that no CNA had been assigned to the resident. LVN2, who was the charge nurse on that shift, stated that at approximately 5 AM it was the first time during that shift that she made rounds and found the resident sitting on the floor in her room. LVN2 reported that she notified the RN Supervisor and that no one responded to help her lift the resident until the 7 AM day shift arrived, noting that at least two staff were required to lift the resident due to a weight of 224 pounds.

When CNA1 and another CNA went to provide care at about 6:20 AM, they found the resident on the floor sitting in feces and were unable to lift her, informing the RN Supervisor and LVN2. CNA1 reported that he and the other CNA signed out at 7 AM, leaving the resident on the floor until the oncoming shift lifted her. The facility’s Director of Nursing stated that no licensed staff informed her that the resident was found on the floor, so no root cause analysis or investigation was initiated. The Director of Staff Development stated she was not informed of the CNA assignment error and that issues affecting residents were required to be communicated immediately to leadership. A physician order summary dated 1/12/2026 directed that floor mats be placed for safety, and the care plan dated 1/12/2026 reiterated that floor mats would be placed as indicated; however, an observation on 2/3/2026 showed that the resident’s room did not have floor mats in place. Facility policies on falls and on accident/incident investigation required that a resident found on the floor be considered to have had a fall and that an investigation be initiated and documented within 24 hours, but this was not done for this event.