F0689

E

Failure to Implement Fall-Prevention Measures and Safe Bed Mobility Assistance for a High-Risk Resident

Mission Hills, California Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision and fall-prevention measures for a resident with a known high risk for falls. The resident, originally admitted in 2019 and readmitted in 2024, had diagnoses including chronic diastolic CHF, a right shoulder rotator cuff tear/rupture, T11–T12 wedge compression fracture sequela, and muscle weakness. A fall risk assessment completed on 12/20/2024 showed a fall risk score of 28, indicating high risk, and documentation from that date showed the resident experienced a fall while ambulating to the restroom and being assisted to the floor by staff. Despite this, there was no documented evidence that the resident’s care plan was revised after the 12/20/2024 fall, and the resident was not added to the facility’s Falling Star Program until 11/1/2025, even though the program policy stated it was to be used as a post-fall intervention for residents at high risk for falls.

The resident’s care plan for functional abilities, initiated on 5/19/2025, indicated the resident required assistance with bed mobility and that two or more staff would assist with bed mobility as needed. The MDS dated 10/27/2025 documented that the resident had intact cognition, was dependent on staff for toileting hygiene, showers, and lower body dressing, required maximal assistance for several bed mobility and ADL tasks, and required partial/moderate assistance for rolling from back to left and right side in bed. On 11/1/2025, during the 11 p.m. to 7 a.m. shift, CNA 1 entered the resident’s room around 6 a.m. to provide morning care, including changing bed linens and incontinence briefs, while the resident was sleeping. CNA 1 reported she did not recall asking the resident if she could hold herself on the side of the bed before starting care, and she proceeded to clean the resident in the supine position and then turn her onto her left side at the edge of the bed while attempting to place a bed protector.

During this care on 11/1/2025, CNA 1 held the resident’s right arm with her right hand while trying to place the bed protector with her left hand. Approximately 10–15 minutes after initiating care, while the resident was lying on her left side at the edge of the bed, the resident slipped from CNA 1’s hold and fell to the floor. There was no floor mat next to the bed at the time of the fall, despite later care plan documentation (initiated after the fall) indicating the resident was to have bilateral floor mats. The incident report and nursing documentation described a laceration to the left eyebrow area, skin tears on the left forehead and left wrist/forearm, visible bleeding on the resident’s face and on the floor, and the need for wound cleansing and pain management. The resident was transferred to an acute care hospital, where she received seven sutures to the left eyebrow laceration.

Following the 11/1/2025 fall, the facility did not complete a fall risk assessment specific to that episode, even though facility policy required fall risk assessments upon admission, quarterly, and after a fall. Licensed nursing staff later acknowledged there was no fall risk assessment completed after the 11/1/2025 fall and that this could result in incomplete or inaccurate fall-prevention interventions. Multiple nurses also confirmed that the care plan had not been updated after the 12/20/2024 fall to include fall-prevention interventions discussed in the IDT meeting, and that the resident was not placed in the Falling Star Program until 11/1/2025, despite having a high fall risk score and a prior fall. Additionally, during a later observation of the resident’s room, no floor mat was present next to the bed, even though the care plan for a witnessed fall (initiated after the incident) called for bilateral floor mats. Staff interviews consistently indicated that licensed nurses were responsible for ensuring care plan interventions were implemented and that CNA 1 should have requested additional assistance when providing bed mobility and morning care to this resident.