Two Falls in Less Than An Hour
The incident occurred during the early morning hours of June 24, 2024, when a cognitively impaired resident experienced back-to-back falls that highlighted critical gaps in the facility's supervision protocols. At 1:20 AM, a certified nursing assistant discovered the resident sitting on the floor near their bed, having fallen while attempting to get up unassisted. Despite finding the resident unharmed from this initial fall, staff failed to implement enhanced monitoring measures.
Less than an hour later, at 2:15 AM, the same resident fell again. This time, the resident's roommate called for help, and staff found the resident on the floor with a head laceration and blood on their arm and gown. Emergency transport was immediately called due to the head injury.
Hospital X-rays and CT scans revealed the severity of the second fall's impact: a moderately displaced left femoral subcapital neck fracture. The injury required the resident to undergo left hip hemiarthroplasty - a partial hip replacement surgery - on July 1, 2024.
History of Fall Risk Ignored
Medical records showed the facility was well aware of the resident's vulnerability. The resident had been admitted on June 7, 2024, with diagnoses including traumatic subarachnoid hemorrhage and documented gait abnormalities. A fall risk evaluation conducted that same day classified the resident as high risk for falls.
The resident's assessment revealed severe cognitive impairment and substantial physical limitations. According to the Minimum Data Set assessment from June 11, the resident required substantial to maximal assistance for basic activities including toileting, dressing, and personal hygiene. The resident normally used both a walker and wheelchair for mobility and had experienced a fall in the month prior to admission.
Despite these documented risk factors, the facility's response to the resident's increasing confusion and agitation on the night of June 23-24 was inadequate. The CNA reported that the resident was "very confused and could not sleep" starting at 11 PM on June 23. The CNA had to repeatedly redirect the resident back to bed after finding them walking unassisted to the bathroom.
Critical Supervision Failures
The investigation revealed multiple breakdowns in the facility's supervision protocols. After the first fall, the CNA positioned themselves in the hallway to monitor call lights but could not see inside the resident's room from that location. The CNA testified that the supervising Licensed Vocational Nurse provided no specific instructions to increase monitoring after the first fall.
When falls occur in nursing homes, standard protocol requires immediate reassessment and implementation of enhanced supervision measures. For residents with severe cognitive impairment who demonstrate repeated attempts to get up unassisted, facilities typically implement 15-minute checks or one-on-one supervision to prevent subsequent falls and injuries.
The facility's Director of Nursing later confirmed that proper protocol would have required staff to increase supervision from every two hours to every hour, or even every 15 minutes, given the resident's agitation and repeated attempts to get out of bed. The DON stated that a CNA should have stayed with the resident as needed for safety, and the care plan should have been immediately revised with new interventions after the first fall.
Pattern of Inadequate Response
The timeline of events reveals a pattern of missed opportunities to prevent harm. Between 11 PM and 1:20 AM, the CNA observed the resident attempting to get up unassisted at least three times. Each incident demonstrated the resident's confusion and inability to recognize safety risks, yet no additional safeguards were implemented.
The facility's own policies, reviewed during the inspection, emphasized that "resident supervision was a core component of the systems approach to safety" and noted that supervision "may need to be increased when there was a change in the resident's condition." The policies also required staff to re-evaluate and implement additional interventions when residents continued to fall despite initial measures.
Physical therapy records from June 23 indicated the resident could ambulate 150 feet with a walker when provided minimal assistance. However, the resident's severe cognitive impairment meant they could not reliably remember to use assistive devices or call for help, making close supervision essential for safety.
The investigation found no documentation that medication was administered to help calm the resident's agitation during the overnight shift, despite the CNA's statement that the LVN gave medication after the first fall. The medication administration record showed no entries for the 11 PM to 7 AM shift on June 23-24.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Monrovia Post Acute from 2024-07-22 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.