F0684

D

Failure to Timely Assess and Revise Care Plan After Unwitnessed Fall

Riverside, California Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The facility failed to ensure timely and ongoing assessment, monitoring, and care-plan revision following a resident’s change in condition after an unwitnessed fall. The resident, admitted with diagnoses including muscle weakness and dementia, was found on January 23, 2026, in a sitting position on the bathroom floor holding onto the toilet, with no apparent injury, intact skin, no complaints of pain, vital signs within normal limits, and alert and oriented at baseline. A late-entry progress note documented this event as a change in condition, with the resident verbally stating that she slipped and did not hit her head. However, there was no documented evidence that staff conducted ongoing assessments for delayed injuries or monitoring on January 23 and January 24 following the unwitnessed fall.

Record review further showed there was no documentation that the resident’s care plan was reviewed or revised to address the fall or to implement interventions to prevent further incidents. An LVN reported that he was assigned to the resident the day the responsible party called about the resident having a black eye and not being informed, and he stated he had not received any report of a change in condition due to a fall. He also stated that, per facility practice, once a resident has a change in condition, the licensed nurse should assess the resident for the next 72 hours, but the change-in-condition documentation was not created until two days after the fall, and ongoing monitoring and assessment did not begin until the day after the fall. The DON confirmed that the incident was a change in condition and that, because the change-in-condition process was not initiated, there was no ongoing assessment, monitoring, or care-plan revision for the resident.