F0689

G

Failure to Adequately Supervise High-Risk Resident and Reliance on Non-Functioning Bed Alarm

South Lake Tahoe, California Survey Completed on 02-04-2026

Penalty

Fine: $14,0153 days payment denial

Summary

The deficiency involves the facility’s failure to provide adequate supervision and assistance to prevent an avoidable fall for a resident identified as high risk for falls. The resident was admitted with multiple diagnoses including aftercare following right hip arthroplasty, dementia, and a history of frequent falls. The resident’s fall risk evaluation showed a high fall risk score, and the admission MDS documented severely impaired cognitive status. Physician orders included use of a bed pad alarm every shift and a clip alarm while in a wheelchair. The fall risk care plan identified the resident as at risk for falls, with goals to reduce falls and injuries and interventions such as staff assistance with ambulation and transfers, use of bed pad and clip alarms, and environmental evaluation for fall risks. However, the care plan did not address the resident’s poor safety awareness and did not include hourly checking and monitoring, despite the resident’s inability to use a call light and impaired cognition.

On the day of the incident, the resident was observed by staff ambulating in the hallway directly outside his room without an assistive device or staff assistance, despite having poor balance and requiring one-person assistance for all walking and transfers. According to the post-fall evaluation, the resident was unsteady, not using his walker, lost his balance, and fell to the right, landing on his right side and hitting the back of his head. Staff reported that the bed pad alarm, which was intended to alert them when the resident attempted to get out of bed, did not sound when the resident got up unassisted. The DON and LN stated that the resident’s bed pad alarm did not go off, and the DON acknowledged that staff were supposed to round on residents every hour, especially those at high risk for falls, but these visual checks were not documented. A CNA reported that earlier that day the resident had been up in a wheelchair for a long time, appeared very tired, and was transferred to bed with the bed pad alarm activated, as indicated by two short beeps.

Following the fall, the resident was noted to be in significant pain, unable to move his lower extremities, and was transferred to the ED. ED documentation and CT imaging revealed a displaced fracture of the right femur with associated intramuscular hemorrhage and severe deformity of the right femur. The resident was subsequently airlifted to another hospital for further evaluation and treatment and was later placed on comfort care and died three days after the fall. Interviews with the PT indicated that, although the resident had become stronger with therapy, he still required staff assistance with transfers and had poor balance, with difficulty standing and a tendency to fall backward earlier the same day. The DON stated that pad alarms did not require routine functionality checks and were assumed to work for 30 days, and the facility was unable to determine why the alarm did not activate when the resident got up. During a tour of another hall, surveyors also observed another high fall risk resident with a bed pad alarm sounding and a call light blinking without staff present in the hallway or at the nursing station, demonstrating reliance on alarms without immediate staff response. A requested policy addressing resident safety, supervision, and accident prevention was not provided.