Resident 3 weighed 252 pounds and had paraplegia, morbid obesity, and cognitive deficits when the fatal fall occurred around 9:30 p.m. Her bed was elevated approximately three feet off the ground with no landing mats on the floor.
Certified Nursing Assistant 1 told inspectors she elevated the bed to waist height — about three feet — and rolled the resident onto her left side to change an incontinence brief. The aide placed the resident's hand on a handrail while supporting her hip, then removed her left hand to unfasten the brief tab.
"Resident 3 let go of the handrail and fell face down," CNA 1 stated. "Resident 3's legs went off the bed causing her to fall to the floor."
The resident's roommate, who witnessed the incident through a partially closed curtain, told inspectors there was only one staff member assisting. The roommate said she heard the fall and that Resident 3 landed face-first near her own bed.
CNA 1 ran from the room yelling "code blue" after finding the resident motionless on the floor. Licensed Vocational Nurse 1 arrived to find Resident 3 face-down with a 3-inch laceration on her left eyebrow and blood pooling around her head.
The nursing assistant had never requested help from another staff member before performing the care, she told inspectors. She also failed to change the resident's low air loss mattress from alternating pressure mode to static mode, which would have made the surface firm during care.
Paramedics arrived at 10:10 p.m. to find Resident 3 "laying supine on ground naked with approximately 3-inch laceration to left eyebrow and approximately 1 liter of blood next to his head." The resident was 18 inches from the wall in the middle of the room.
Staff took five minutes to produce documentation showing the resident had a do-not-resuscitate order. Paramedics declared Resident 3 dead at 10:21 p.m.
The facility's own assessment records contradicted how staff provided care. Resident 3's MDS assessment indicated she was "dependent" and required staff assistance for eating, toileting, dressing, and rolling in bed. The assessment specifically showed she needed two-person assistance.
However, her care plan listed only "one-person assist" for generalized weakness.
Registered Nurse 2 acknowledged the discrepancy during interviews with inspectors. "If MDS was not accurate, the plan of care will also not be accurate," the nurse stated. "It placed the resident at risk of improper care."
The Director of Nursing confirmed the care plan failed to match the resident's actual needs. "Resident 3 would have benefited with a 2-person assistance due to Resident 3's diagnosis of left side weakness," the DON told inspectors.
The nursing assistant had worked at the facility since her hire date but told inspectors she was instructed never to adjust the low air loss mattress settings. She said she "never had a nurse change the LAL mattress setting when doing care for Resident 3" during her entire employment.
Treatment Nurse 1 explained that the mattress should have been switched to static mode during care. "If LAL is not on static mode the LAL mattress will move and will inflate one side and deflate the other," the nurse stated. Only licensed nurses could change the setting from 300 pounds to static mode.
The mattress manufacturer's manual confirmed that static mode should be used during "caregiving" and would automatically revert to alternating pressure after 120 minutes.
LVN 1 told inspectors that Resident 3 normally required "2 or 3 staff depending on how small the staff was, for care." The licensed nurse said the bed was "too high, possibly three feet off the ground" and noted there was no landing mat.
Resident 3 had bilateral upper and lower extremity impairments and was described as bed-bound but alert and oriented to herself. She received nutrition through a gastrostomy tube and took daily aspirin to prevent blood clots.
The facility admitted Resident 3 with orders for a low air loss mattress set at 300 pounds, with staff required to check settings and function every shift. Her care plan specifically called for monitoring "proper setting and functioning of the LAL, every shift."
Federal inspectors found the facility failed to provide adequate supervision and assistance devices to prevent accidents. The violation received an "immediate jeopardy" citation, the most serious level indicating substantial likelihood of death or serious harm.
The facility is disputing the citation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Meadows On Sunset Post Acute from 2024-08-09 including all violations, facility responses, and corrective action plans.
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