SPOKANE, WA - The Gardens On University nursing facility faced significant regulatory violations during a June 2024 inspection, with investigators documenting failures in fall prevention protocols, trauma-informed care practices, and dementia behavior management that placed vulnerable residents at risk.
Resident Sustains 13 Falls in 44 Days Due to Inadequate Safety Protocols
The most serious violation centered on a cognitively impaired resident who experienced 13 falls in just 44 days between April and June 2024. The resident, identified as having non-traumatic brain dysfunction, transient ischemic attacks, and reversible encephalopathy, was classified as high risk for falls due to their history of falling and tendency to overestimate their physical capabilities.
Despite facility policies requiring immediate implementation of new fall interventions after each incident, investigators found systematic failures in the facility's response. The resident experienced falls on multiple dates including April 23, May 1, May 7, May 10, May 17, May 23, May 24, May 28, and May 30 (twice), June 2, June 5, and June 6, 2024.
Critical documentation gaps emerged during the investigation. When inspectors requested all 13 fall incident reports, the facility initially provided only 8 reports. After a second request, they still failed to provide documentation for the June 2 fall, indicating incomplete record-keeping for mandatory safety incidents.
The facility's response to these repeated falls revealed concerning delays in medical evaluation. After the May 7 fall, a pharmacy medication review was completed six days later, but the physician didn't review the pharmacist's recommendations until 31 days after the fall occurred. This delayed response contradicts established protocols for timely medical assessment following resident injuries.
Ineffective Fall Prevention Measures Despite Multiple Interventions
The resident's care plan documented numerous attempted interventions, including call light placement, visual cues, scheduled toileting, nighttime checks, fall mats, specialized call buttons, and ultimately one-on-one supervision. However, the implementation and effectiveness of these measures proved inadequate.
Particularly concerning was the facility's inconsistent application of one-on-one monitoring. After implementing this intensive supervision measure on May 30 following a dining room fall, the resident fell again that same evening with no documentation indicating the monitoring was in place. This pattern repeated during subsequent falls on June 5 and June 6, when incident reports showed the resident was "found on the floor in their room alone and unattended" despite supposedly having continuous supervision.
Falls in nursing homes represent a significant patient safety concern, with approximately 1,800 deaths annually resulting from fall-related injuries in long-term care facilities. For residents with cognitive impairment, the risk increases substantially due to their inability to recognize safety limitations and remember instructions. Effective fall prevention requires immediate assessment of contributing factors, swift implementation of targeted interventions, and continuous monitoring of intervention effectiveness.
The failure to prevent repeated falls in cognitively impaired residents can lead to serious injuries including hip fractures, head trauma, and decreased mobility. Each fall also increases anxiety and fear, potentially leading to further functional decline and reduced quality of life.
Trauma-Informed Care Failures Expose Domestic Violence Survivor to Retraumatization
The facility also failed to provide appropriate trauma-informed care for a resident with a documented history of domestic violence and Post-Traumatic Stress Disorder. Hospital records clearly indicated the resident had experienced verbal and physical abuse from their spouse and required alternative living arrangements due to an "emotionally abusive and unkept environment."
Despite this known trauma history, the facility's initial assessment documented that the resident "had not experienced or witnessed any traumatic events," directly contradicting hospital documentation. More critically, the facility placed this domestic violence survivor in a room with a roommate known for aggressive, verbal outbursts - a potentially retraumatizing environment.
The incident occurred just one day after admission when "Resident 3 was aggressively grabbed by the arm by their roommate when the roommate experienced an episode of agitation. Resident 3's roommate was aggressive, screamed, and struck out. Resident 3 was confused by the roommate's aggressive behaviors and was moved out of the room."
Missing Trauma Triggers and Safety Protocols
The resident's care plan contained no trauma-specific interventions or identified triggers despite clear documentation of PTSD and domestic violence history. Staff interviews revealed widespread understanding that trauma triggers should be documented and avoided, yet none were implemented for this resident.
Adding to the concerning pattern, while the facility posted a notice in May 2024 prohibiting the abusive spouse from visiting and instructing staff to contact law enforcement if seen on premises, this protection wasn't implemented until two months after admission despite early knowledge of the domestic violence history.
Trauma-informed care represents a fundamental shift in approaching residents who have experienced significant adverse events. Research demonstrates that failure to implement trauma-informed practices can lead to retraumatization, increased anxiety, depression, and behavioral issues. For domestic violence survivors, exposure to aggressive behaviors, loud voices, or feeling trapped can trigger traumatic memories and psychological distress.
Proper trauma-informed care requires comprehensive assessment of trauma history, identification of specific triggers, development of individualized coping strategies, and environmental modifications to prevent retraumatization. The absence of these protocols places vulnerable residents at risk for psychological harm and impedes their recovery process.
Inadequate Dementia Behavior Management Lacking Individualized Interventions
The facility's dementia care practices also fell short of regulatory requirements. A resident with stroke-related dementia experienced frequent behavioral episodes including verbal outbursts, hallucinations, and prolonged distress periods lasting up to two and a half hours. The resident's documented behaviors included screaming obscenities and threatening statements directed at staff and other residents.
Despite facility policies emphasizing person-centered, non-pharmacological approaches to behavior management, the care plan lacked individualized interventions. Staff interviews revealed they had "no known behavioral interventions to attempt" despite the resident's escalating behaviors occurring "several times per week."
Staff noted that behaviors often occurred during personal care activities and when the resident couldn't see out of their room due to privacy curtains. One staff member observed that behaviors decreased when they addressed the resident's delusion about caring for a baby, yet this effective intervention wasn't incorporated into the care plan.
Medical Context and Industry Standards
Dementia-related behaviors typically stem from unmet needs, environmental factors, physical discomfort, or inability to communicate effectively. Evidence-based dementia care emphasizes identifying behavior triggers, implementing person-centered interventions, and continuously evaluating effectiveness. The facility's approach of simply closing doors "to muffle the noise" when residents experienced prolonged distress periods represents inadequate care that fails to address underlying needs.
Professional standards require systematic assessment of potential behavior causes including pain, medication side effects, environmental stressors, and unmet basic needs. Effective interventions might include pain management adjustments, environmental modifications, structured activities, and communication techniques tailored to the individual's cognitive abilities and personal history.
Additional Issues Identified
The inspection also documented problems with incident report completion, with several reports containing "numerous question marks, missing information, and was mostly left blank." This incomplete documentation hampers the facility's ability to analyze incident patterns and implement appropriate preventive measures.
Staff interviews consistently demonstrated understanding of proper protocols, yet implementation failures occurred across multiple departments. The disconnect between policy knowledge and practical application suggests systemic issues with care plan implementation and staff supervision.
The facility had previously received citations for fall management failures in February 2024 and October 2023, indicating ongoing problems with accident prevention protocols despite repeated regulatory oversight.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Gardens On University, The from 2024-06-12 including all violations, facility responses, and corrective action plans.
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