F0689

D

Failure to Implement and Document Fall Precautions for High-Risk Resident

Compton, California Survey Completed on 02-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement and document fall risk interventions, including visual checks and monitoring, for a resident identified as a fall risk, which resulted in an unwitnessed fall. The resident had diagnoses including age-related osteoporosis with pathological fracture, history of falling, dementia, and osteoarthritis of both hips. An H&P noted the resident had capacity to understand and make decisions, while an MDS assessment documented severely impaired cognitive skills for daily decision-making, bilateral lower extremity impairment, and the need for assistance with transfers and ambulation, with wheelchair use for mobility. Multiple care plans identified the resident as at risk for falls due to history of falls, hypoxia, impaired balance, and brain injury, with goals for the resident to remain free of falls and interventions including placement on the Falling Star (Yellow Star) Program and initiation of fall risk precautions.

Care plans and the facility’s fall prevention program required monitoring and documentation of fall risk interventions, including closer monitoring, frequent rounds, and visual checks for residents on fall precautions. The Falling Star Program used a yellow star outside the resident’s room to identify fall risk and called for the bed to be in the lowest position and floor mats on both sides of the bed. The Quality Assurance Nurse stated that residents on fall precautions were to be monitored closely by CNAs, with documentation of monitoring on ADL task flowsheets, and that visual checks required hourly documentation on a Visual Observation Log posted in the resident’s room. However, review of nursing progress notes from 1/20/2026 through 1/23/2026 and the ADL documentation for January 2026 showed no documented monitoring or visual checks for the resident prior to the fall, with the last CNA entry recorded the night before the fall. The QAN acknowledged that in the absence of documentation, there was no way to determine whether fall risk monitoring or interventions were implemented.

On the date of the incident, a Change in Condition evaluation documented that the resident was found on her right side on the floor, with a skin tear to the right upper extremity, and the resident stated, "I rolled out of bed." A Post Fall Evaluation recorded that the unwitnessed fall occurred in the resident’s room when the resident rolled out of bed, and that no floor mat was present at the time of the fall. Subsequent nursing documentation noted an acute right pelvic fracture and transfer to a general acute care hospital for further evaluation and treatment. Staff interviews revealed inconsistent awareness and implementation of fall precautions: one CNA reported making 20–30 minute rounds and visual checks on fall-risk residents but not documenting this, another CNA described the resident’s repeated attempts to get out of bed and into a wheelchair, and a nurse stated she did not know the resident was a fall risk and therefore did not implement increased visual checks. Observations after the fall showed the resident attempting to get out of bed, with low bed and floor mats in place, but without a Falling Star symbol posted outside the room, despite the resident being on the Falling Star Program. Facility policies on charting, falls and fall risk management, and assessing falls required staff to monitor, evaluate, and document interventions and resident responses, which were not carried out or documented as required for this resident.