F0689

G

Unwitnessed Fall and Head Injury Due to Inadequate Supervision in Memory Care

Houston, Texas Survey Completed on 03-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision and maintain an environment free from accident hazards for a cognitively impaired resident in the memory care unit. The resident was an elderly female with dementia with psychotic disturbance, severe cognitive impairment (BIMS score of 00), altered mental status, restlessness and agitation, gait impairment, lack of coordination, and a history of unintentionally walking into objects and removing footwear. Her care plan identified ADL deficits, the need for staff to anticipate needs and provide prompt assistance, supervision with one staff for walking in the room and corridor, limited assistance for locomotion on and off the unit, frequent checks during high‑risk times, maintaining safety during increased wandering, and offering engaging activities to reduce restlessness. The care plan also noted impaired communication, risk for further decline and injury, and the need to reduce environmental stimuli and use communication tools the resident could understand.

On the day of the incident, the resident was wandering in the memory care dining room and was known by staff to walk continuously, not remain seated, and be unable to communicate needs verbally. CNA A reported placing the resident on a couch in the dining area and then leaving to provide care to another resident without notifying other staff or providing a handoff of supervision, despite the expectation that residents in the memory care unit be supervised at all times and that staff verbally pass on supervision responsibilities before leaving an area. CNA B stated she was at the nurses’ station charting and was not directly observing the resident, did not see or hear the fall, and was unaware of the exact whereabouts of other staff. She reported that she had been charting for about five minutes before noticing the resident on the floor in the dining room and was unsure how long the resident had been on the floor. LVN A stated she was seated at the nurses’ station documenting, could only see a portion of the dining room from that position, and was notified by CNA B that the resident was on the floor.

The fall was unwitnessed, and the resident was found on the floor in a seated position on her bottom in the dining room. Initial assessment by LVN A documented stable vital signs and no visible injuries or pain at that time, and the environment around the fall was noted to have no notable findings. Later, swelling and a nodule/hematoma developed on the right side of the resident’s forehead, with subsequent discoloration to the right side of the face above the eyebrow, below the eye, and toward the nose. The resident was sent to the hospital, where imaging and tests were described as reassuring, and instructions were given to ice the hematoma. Facility leadership, including the ADON, DON, and Administrator, stated that residents in the memory care unit, and this resident in particular, required constant or continuous supervision due to wandering, inability to ensure their own safety, and communication deficits, and that staff were expected to maintain direct visual observation and communicate supervision coverage. Staff interviews and observations confirmed that at the time of the incident, the resident was not under continuous direct observation, supervision responsibilities were not properly handed off, and the nurse’s station position did not allow full visibility of the dining room, leading to the unwitnessed fall and resulting head injury.

Subsequent observation of the resident by the surveyor showed that she ambulated independently but experienced brief losses of balance every few steps or when stopping, did not respond verbally, and did not allow staff to assist for more than a few seconds before moving away. LVN C confirmed that the resident never sat still, including during meals, did not communicate verbally, and required continuous direct observation to ensure safety. The facility’s own policies on Dementia Care, Fall Management, and Standards of Care required person‑centered care, individualized fall prevention plans, supervision during high‑risk activities such as ambulation, and safety measures to prevent accidents and injuries. Despite these policies and the resident’s documented risks and care plan interventions, staff actions and inactions at the time of the incident resulted in the resident being unsupervised in the dining room, an unwitnessed fall, and a hematoma to the forehead requiring hospital evaluation.