TACOMA, WA - A long-term care facility experienced multiple serious failures in fall prevention protocols, resulting in a resident sustaining a hip fracture after falling from a wheelchair at the nursing station, according to a March 2025 federal inspection report.
Repeated Falls Lead to Hip Fracture
Alaska Gardens Health and Rehabilitation faced scrutiny after investigators documented systemic breakdowns in fall prevention measures affecting multiple residents. The most severe case involved a resident with Parkinson's disease and cognitive impairment who experienced three documented falls within a two-week period, culminating in a fractured hip that required surgical intervention.
The resident, who had a history of falls prior to admission, first fell on a January afternoon while attempting to stand from a wheelchair without assistance at the nursing station. According to the inspection narrative, facility staff documented they would "encourage resident to remain in highly supervised area when in wheelchair," yet no substantive changes were implemented in the resident's care plan.
Two days later, the same resident fell again while attempting to stand without assistance in their room. A certified nursing assistant attempted to intervene but was unable to prevent the fall. Following this second incident, the facility indicated plans to increase supervision and update the care plan, but documentation revealed these changes were not implemented promptly.
The third fall occurred approximately one week later, again at the nursing station. The resident stood up from the wheelchair and fell onto their buttocks. According to witness statements, staff members saw the resident begin to stand but could not reach them in time to prevent the fall.
Days after the third fall, the resident's family found them slumped over in the wheelchair at the nursing station, barely responsive. Emergency medical services were called, and hospital evaluation revealed the resident was over-sedated from psychotropic medications and had sustained an acute hip fracture requiring surgery.
Failure to Implement Evidence-Based Fall Prevention
Federal regulations require nursing facilities to develop individualized, resident-centered fall prevention programs that address specific risk factors. The inspection revealed Alaska Gardens failed to meet this standard in multiple ways.
The resident's initial fall care plan, dated from admission, contained only generic interventions such as "announce themselves when approaching resident" and "ensure nonskid footwear." These interventions were not tailored to address the resident's specific risk factors, which included Parkinson's disease, cardiac rhythm problems, hallucinations, and frequent pain rated as high as 8 out of 10 on a standard pain scale.
Hip fractures represent one of the most serious complications of falls in older adults, particularly those with pre-existing conditions like Parkinson's disease. When a resident has progressive neurological impairment combined with untreated pain, their fall risk increases substantially. Pain can cause residents to shift position suddenly or attempt to stand without thinking to call for assistance.
The facility's own policy required implementing a fall prevention plan to reduce specific risk factors for each at-risk resident. The policy also mandated that physicians and consultant pharmacists identify and adjust medications known to increase fall risk. However, documentation showed the resident was prescribed antipsychotics and antidepressants—both medication classes associated with high fall risk—without evidence of medication review or adjustment after the falls began occurring.
Breakdown in Post-Fall Monitoring Protocols
When falls occur, established clinical protocols require immediate assessment, physician notification, and enhanced monitoring for delayed complications. Alaska Gardens' own policy mandated placing residents on "alert charting" with vital signs checked every shift for 72 hours following any fall to monitor for pain, injury, changes in consciousness, or balance problems.
Investigators found no evidence this monitoring occurred consistently after any of the three falls. Progress notes failed to document the fall events themselves for two of the three incidents. There was no documentation showing the physician and family were notified after the second and third falls, contradicting both facility policy and the family's account.
The facility's fall investigation reports were incomplete. They did not include thorough analysis of the circumstances leading up to each fall, identify unmet care needs, or document what prevented staff from providing adequate supervision despite the resident being positioned at the nursing station specifically for closer monitoring.
According to hospital records, when the resident was finally transferred for emergency care, physicians discovered the hip fracture only after the resident became more alert and attempted to stand during physical therapy. The resident showed facial grimacing and guarded their right hip—classic signs of acute fracture that should have been detected earlier with proper post-fall assessment protocols.
Falls resulting in fractures often involve a delay between the initial injury and clinical recognition, particularly in residents with cognitive impairment who may not effectively communicate pain. This makes the 72-hour enhanced monitoring period critical. Neurological checks and systematic pain assessments at each body site can identify injuries that are not immediately obvious.
Inadequate Supervision Despite High-Risk Status
The inspection revealed a fundamental contradiction in the resident's care: they were identified as requiring constant supervision and positioned at the nursing station for this purpose, yet fell three times while supposedly under direct observation.
After the first fall, documentation stated the resident would be kept "in highly supervised area when in wheelchair." After the second fall, the plan included placement on the Fall Prevention Program to "increase supervision." Yet the third fall occurred at the nursing station with the resident in their wheelchair—the exact location where they should have been receiving the promised enhanced supervision.
The facility's Fall Prevention Program included specific components: blue tags on doors, blue armbands identifying high-risk residents, non-skid socks, informational sheets above beds listing specific interventions, and fall binders at nursing stations. However, investigators found these elements were inconsistently implemented or absent entirely.
Staff interviews revealed confusion about the program. One certified nursing assistant stated they had "never seen residents wear blue wrist bands." A licensed practical nurse was "unsure what the significance was of the blue name tags." An administrator acknowledged that "some of the components of the Fall Prevention Program were not done at the facility."
The Kardex—a quick-reference document certified nursing assistants use to implement care plans—showed no fall prevention interventions for this resident on multiple dates reviewed, meaning frontline caregivers had no documented guidance on fall prevention measures during routine care.
Care Plan Updates Delayed and Incomplete
Regulatory standards require care plans to be updated promptly when a resident's condition changes or interventions prove ineffective. The inspection documented significant delays in updating this resident's fall prevention strategies.
After the first fall on a Wednesday afternoon, the care plan was not updated until the following Monday—four days later and two days after the second fall had already occurred. The intervention added at that time was to keep the resident "in a highly visualized area when in the wheelchair," which addressed the first fall but came too late to prevent the second.
Following the second fall, the plan was updated to include mental health referral and enrollment in the Fall Prevention Program, but again, this occurred two days after the incident. After the third fall, investigators found the facility planned to install auto-lock brakes on the wheelchair, but no physician orders were obtained for this intervention, meaning it likely was not implemented.
Notably absent from the care plan updates were interventions addressing the resident's significant pain levels or review of their psychotropic medications, both of which were contributing factors. Physical therapy notes showed the resident ambulated 60 feet with minimal assistance just days before the third fall, yet after that fall, therapy staff documented the resident was unable or unwilling to stand even with maximum assistance from two staff members. This dramatic functional decline was not reported to nursing or physician staff for evaluation.
Additional Cases Reveal Systemic Problems
The inspection identified similar failures affecting other residents, indicating the problems were not isolated incidents but reflected systemic deficiencies in the facility's fall prevention program.
A second resident experienced two falls within two hours on the same evening. The first fall occurred when the resident slid off the bed while preparing for sleep. Just two hours later, the resident fell again from the bed while attempting to reach the bathroom. According to the family, the resident had reported that call lights were frequently out of reach and response times were long, leading to attempts at self-transfer.
The facility's investigation of these falls lacked critical elements. There were no signed witness statements, no documentation of whether the call light was within reach or had been activated, and no analysis of why the resident felt compelled to attempt bathroom transfers independently. The proposed intervention—providing a wider bed—was identical for both falls and did not address the resident's need for more responsive toileting assistance.
Physician orders were obtained for side rails and floor mats, but these interventions were not transcribed into the care plan or Kardex for implementation. The wider mattress that was ordered was not provided until four days after the falls. Meanwhile, the Kardex showed no fall prevention interventions at all on the dates reviewed, leaving certified nursing assistants without guidance on how to prevent future falls for this resident.
A third resident's case illustrated failures in maintaining interventions already in place. The resident's care plan specified keeping the right side of the bed against the wall, yet during the inspection, surveyors observed the bed was not positioned against the wall and was not in the lowest position as required. An IV pole and oxygen concentrator were positioned between the bed and wall. The blue information sheet that was supposed to list fall interventions was blank and unreachable behind the medical equipment.
Additional Issues Identified
Beyond the fall prevention failures, the inspection documented:
- Inconsistent staff knowledge about the Fall Prevention Program, with multiple staff members unable to explain the significance of program components or how to implement them - Lack of systematic monitoring for residents with repeated falls, with no structured clinical review process comparable to the facility's approach for other high-risk conditions - Communication breakdowns between departments, with therapy staff failing to notify nursing when residents showed sudden functional decline - Missing laboratory results, with staff unable to locate urinalysis results that had been ordered to evaluate possible infection contributing to confusion and fall risk - Failure to ensure care plan interventions transferred to the point-of-care documentation system used by certified nursing assistants who provide direct care
The facility's administrator acknowledged during the investigation that nurses were expected to document fall events, implement 72-hour enhanced monitoring, and update care plans before the end of their shifts, but stated this "was not done timely." The director of nursing was identified as responsible for reviewing documentation to ensure post-fall protocols were completed, but this oversight was clearly ineffective.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alaska Gardens Health and Rehabilitation from 2025-03-19 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.