MONROVIA, CA - A resident at Monrovia Gardens Healthcare Center sustained a serious cervical spine fracture after falling alone in a conference room, despite having a care plan that specifically required frequent monitoring and placement near the nursing station.
The January 24, 2025 federal inspection revealed that the 615 W. Duarte Road facility failed to prevent the December 28, 2024 fall of a high-risk resident who had multiple previous falls and severely impaired cognition.
Serious Spinal Injury from Preventable Fall
The resident, who used a wheelchair and required maximum assistance for mobility, fell while alone in a conference room with the door closed. Medical scans revealed a fracture through the dens - the critical peg-like bone at the top of the second cervical vertebra that allows head rotation.
A dens fracture is among the most dangerous spinal injuries. This type of break can cause nerve compression, potentially leading to paralysis or death if not properly managed. The fracture required the resident to wear a cervical collar and follow up with neurosurgery specialists.
The resident was transferred to a local hospital where an MRI revealed findings concerning for nerve compression, and neurosurgical consultation was recommended. Due to the resident's age and multiple medical conditions, doctors determined surgery would be high-risk, opting instead for conservative treatment with a brace.
Multiple Care Plan Violations
According to inspection records, the resident had been assessed as high-risk for falls due to a history of multiple previous falls, use of psychotropic medications, urinary incontinence, and agitated behavior. The resident's care plan specifically called for frequent visual checks and placement at the nursing station for continuous monitoring.
On the morning of the incident, a certified nursing assistant placed the resident in a wheelchair near the nursing station around 8:30 a.m. When staff returned at noon, the resident was missing from the designated monitoring area and was found on the floor of the conference room with a large bump on the head.
"Resident 12 should not be left in the conference room unsupervised since Resident 12 was confused and at high risk for falls," a registered nurse told inspectors. "Staff did not follow Resident 12's care plans."
Systemic Supervision Failures
The inspection revealed multiple breakdowns in the facility's supervision system. A licensed vocational nurse admitted to inspectors: "We, (staff including LVN 6) did not follow Resident 12's care plans to monitor Resident 12 frequently."
The facility's administrator acknowledged that fall-risk and confused residents should be monitored every one to two hours, but admitted that "no one witnessed Resident 12 going or being taken into the conference room."
Standard nursing home protocols require visual line-of-sight supervision for high-risk residents. When residents with cognitive impairment and fall history are placed in areas where staff cannot see them, the risk of injury increases dramatically.
Medical Consequences of Inadequate Monitoring
Dens fractures occur in the most mobile part of the cervical spine and can be unstable, meaning the broken bone fragments can shift and damage the spinal cord. Even conservative treatment requires strict immobilization and careful monitoring for neurological changes.
The resident's multiple medical conditions - including heart failure, diabetes, and end-stage kidney disease requiring dialysis - complicated both the injury and treatment options. These comorbidities make any traumatic injury more dangerous and recovery more challenging.
Additional Care Deficiencies Found
Inspectors also documented failures in basic daily care assistance. Multiple residents reported delays of up to an hour for diaper changes, with one resident stating that response times "depended on how many residents were assigned to each certified nursing assistants."
The facility also failed to follow individualized care schedules, including missing hair washing appointments that had been specifically arranged at family request.
Facility Standards and Requirements
Federal regulations require nursing homes to provide adequate supervision to prevent accidents and implement individualized care plans. Facilities must identify residents at risk for falls and develop specific interventions to address those risks.
The facility's own policies state that "resident safety supervision and assistance to prevent accidents were facility-wide priorities" and require staff to implement "interventions to reduce individual risks related to hazards in the environment, including adequate supervision."
The inspection classified the fall incident as causing "actual harm" to the resident, indicating that the facility's failures resulted in measurable injury requiring medical intervention.
These violations highlight the critical importance of consistent supervision protocols for vulnerable nursing home residents, particularly those with cognitive impairment and mobility limitations who cannot advocate for their own safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Monrovia Gardens Healthcare Center from 2025-01-24 including all violations, facility responses, and corrective action plans.
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