F0689

G

Failure to Adequately Supervise High‑Risk Resident Resulting in Hip Fracture

Berkeley, California Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision and prevent accidents for a resident with a known high risk for falls. The resident was admitted in early April and had a Minimum Data Set dated in October showing a Brief Interview for Mental Status (BIMS) score of 10/15, indicating moderate cognitive impairment, and a diagnosis of schizophrenia. The MDS documented that the resident used a manual wheelchair, could wheel at least 50 feet, and could walk at least 50 feet with supervision or touching assistance, but was not assessed to walk 150 feet due to medical or safety concerns. A Fall Risk Assessment dated in October showed a fall score of 50 related to a history of falls, unsteady and weak gait, and wheelchair use, and the fall care plan identified the resident as at risk for falls.

The care plan included an intervention dated in September to admit the resident to a high-risk unit, anticipate and meet needs, and follow the facility’s fall protocol. Staff interviews confirmed that the facility had a designated high fall risk unit where staff conducted 15‑minute rounds on high fall risk residents. However, the resident was not moved to this high‑risk unit after a fall on September 10, which had occurred due to loss of balance while ambulating, despite the interdisciplinary team’s recommendation to do so. The administrator later stated the facility decided not to move the resident because there were no injuries from that September fall. As a result, the resident remained outside the high‑risk unit at the time of the subsequent fall.

On the night of the incident in November, the resident ambulated independently in the hallway while returning from the patio after smoking and experienced an unwitnessed fall. Nursing documentation and interviews indicated the resident was found sitting on the ground in the hallway near his room, next to his wheelchair, awake and alert, and complaining of right hip and leg pain. An RN assessed the resident, noted pain in the right hip and groin area, and obtained a STAT X‑ray, which showed an acute comminuted fracture of the right intertrochanteric femur. The resident was transferred to an acute care hospital and underwent right hip surgery. The acting DON later stated that the fall could have been prevented if staff had monitored the resident closely and provided constant supervision while he was walking alone, and the facility’s fall prevention policy required that all residents receive adequate supervision and assistive devices to prevent accidents.