HONOLULU, HI - A recent inspection at Kalakaua Gardens nursing home revealed serious safety failures that resulted in a resident experiencing two preventable falls in the bathroom, with the second incident occurring despite clear warnings from staff about the need for constant supervision.
Pattern of Preventable Falls Emerges at Kalakaua Gardens
The inspection conducted on January 17, 2025, uncovered a troubling sequence of events involving Resident 22, who required moderate assistance with toileting and mobility according to facility assessments. The first fall occurred on September 5, 2024, when a Certified Nurse Aide (CNA) assisted the resident to the bathroom and left her unattended on the toilet. The aide and a Registered Nurse later found the resident on the bathroom floor with her head against the wall.
According to the inspection report, the resident stated: "she hit her head hard against the wall, but she doesn't remember how or why she fell." The resident was subsequently hospitalized and returned with a diagnosis of right superior and inferior ramus fracture - a serious pelvic injury - along with skin tears to her right arm, forearm, and right leg.
The medical significance of pelvic fractures in nursing home residents cannot be understated. These injuries typically result from high-impact falls and can lead to prolonged immobility, increased risk of complications such as blood clots, pneumonia, and significant decline in functional ability. For elderly residents who already require assistance with basic activities, such injuries often mark a permanent reduction in independence and quality of life.
Facility Fails to Implement Safety Measures Despite Clear Warning
Following the initial fall, facility staff completed a Fall Scene Investigation Tool that identified the root cause as the resident's loss of balance while getting off the toilet. The investigation specifically recommended that "R22 should be accompanied to the restroom and to not leave the resident unattended." However, the facility failed to update the resident's comprehensive care plan to reflect these critical safety requirements.
This failure to implement identified safety measures represents a fundamental breakdown in the nursing home's responsibility to protect vulnerable residents. Care plans serve as the primary communication tool between staff members across different shifts, ensuring continuity of care and safety protocols. When safety recommendations are not incorporated into these plans, the risk of repeated incidents increases dramatically.
The resident's assessment data clearly indicated significant mobility challenges. According to the Minimum Data Set assessment from December 6, 2024, the resident required partial to moderate assistance with toileting hygiene, sit-to-stand transfers, and toilet transfers. This level of dependency, combined with documented gait and balance problems and a history of multiple falls, should have triggered heightened safety protocols.
Second Fall Could Have Been Prevented
Despite the clear warning signs and staff recommendations, a second bathroom fall occurred on November 25, 2024. Once again, the resident was assisted to the toilet and left unattended. This time, staff found the resident in a pool of blood from a head laceration, along with skin tears and multiple bruises. The resident required emergency treatment and returned with three sutures above the right eye.
When interviewed during the inspection, the Director of Nursing acknowledged that the resident's care plan had not been updated following the first fall and confirmed that "if R22 was not left unattended, the second fall could have been avoided." This admission highlights the preventable nature of the second incident and represents a clear failure in the facility's duty to provide adequate supervision.
Medical Context and Risk Factors
Falls in nursing homes are a serious public health concern, particularly for residents with mobility limitations. The combination of factors present in this case - documented balance problems, history of falls, and need for moderate assistance with transfers - creates a high-risk profile that requires specialized interventions and constant vigilance.
Bathroom environments present particular hazards for elderly residents due to wet surfaces, hard fixtures, and the complex movements required for toileting. Standard safety protocols in nursing homes typically include ensuring adequate lighting, removing slip hazards, providing grab bars, and most importantly, maintaining appropriate supervision levels based on individual resident needs.
The repeated nature of these falls suggests systemic communication failures within the facility. Proper fall prevention protocols require not only immediate response to incidents but also comprehensive analysis of contributing factors and implementation of preventive measures. This includes updating care plans, educating staff about specific resident needs, and ensuring consistent application of safety protocols across all shifts.
Regulatory Standards and Best Practices
Federal regulations require nursing homes to provide adequate supervision to prevent accidents and maintain an environment free from hazards. Facilities must assess each resident's fall risk and implement appropriate interventions based on individual needs. When a fall occurs, regulations mandate thorough investigation and implementation of measures to prevent recurrence.
Industry best practices for high-risk residents typically include one-on-one supervision during toileting, use of assistive devices, environmental modifications, and comprehensive staff training. The failure to implement basic supervision measures despite clear documentation of need represents a significant departure from accepted standards of care.
Additional Issues Identified
The inspection also revealed deficiencies in the facility's care planning process, with investigators citing failures to ensure proper development and implementation of comprehensive care plans. This violation (F657) was classified as having potential for minimal harm but indicates broader systemic issues with the facility's approach to individualized care planning and risk assessment.
The facility's pattern of failing to learn from incidents and implement corrective measures raises concerns about its overall safety culture and commitment to resident protection. Effective nursing home operations require continuous quality improvement processes that identify risks, implement interventions, and monitor outcomes to prevent harm.
These violations underscore the critical importance of proper supervision and care plan implementation in nursing home settings, where vulnerable residents depend on facility staff to recognize and address safety risks before they result in preventable injuries.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Kalakaua Gardens from 2025-01-17 including all violations, facility responses, and corrective action plans.
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