HANFORD, CA - A 93-year-old resident at Hanford Post Acute died from brain injuries after a series of preventable falls that staff failed to address despite multiple warning signs, according to a federal inspection report that revealed critical breakdowns in fall prevention protocols.
Pattern of Unwitnessed Falls Goes Unaddressed
The tragic case began unfolding in September 2024 when the resident, who had dementia and moderate cognitive impairment, experienced his first documented fall. Over the next five months, the facility documented six separate falls, all occurring in the resident's room while he was unsupervised.
The falls followed a disturbing pattern: September 30, 2024 at midnight; November 5, 2024 at 7:04 p.m.; December 9, 2024 at 4:00 p.m.; December 16, 2024 at 10:00 p.m.; December 18, 2024 at 9:09 a.m.; and February 1, 2025 at 4:12 p.m. In each instance, the resident was found on the floor next to his bed.
The February 1st fall resulted in a laceration above his left eyebrow that required emergency department treatment and sutures. Despite this escalation, the facility's response remained inadequate. Two more falls occurred on March 11th and 12th, with the final fall causing fatal brain injuries.
A Licensed Vocational Nurse acknowledged the inadequacy of the care provided, stating during the inspection that the resident "needs supervision and continuous monitoring for his safety and was not provided."
Critical Gap in Fall Risk Assessment and Response
Federal regulations require nursing homes to assess residents' fall risk and implement appropriate interventions. For residents with dementia and a history of falls, this typically includes enhanced monitoring, environmental modifications, and one-on-one supervision when indicated.
The resident's medical profile presented multiple fall risk factors that should have triggered intensive prevention measures. His admission record showed diagnoses of dementia, abnormal gait and mobility issues, and osteoarthritis. A cognitive assessment revealed moderate impairment with a score of 10 out of 15, indicating significant deficits in memory and judgment that would affect his ability to make safe decisions about mobility.
Staff interviews revealed they were well aware of the resident's high fall risk. A Certified Nursing Assistant familiar with his care described him as "wobbly and unsteady when standing up" and stated he "was not safe to get out of bed on his own and needed supervision because he was unsteady on his feet." The CNA emphasized that the resident "was impulsive and needed one-on-one monitoring to keep him safe and prevent falls."
However, despite this clear understanding of his needs, the facility failed to implement appropriate interventions. The Assistant Director of Nursing admitted during the inspection that "the interventions of keeping call light within reach, and encouraging to use would not address the cause of the falls, which occurred when he was unsupervised in his room."
Medical Consequences of Inadequate Fall Prevention
Falls among elderly residents with dementia can have devastating consequences, particularly when blood-thinning medications are involved. This resident was taking anticoagulant medication, which significantly increased his risk of serious bleeding from any trauma.
The March 12th fall proved fatal when the impact caused multiple types of brain bleeding. Emergency department physicians documented an intracranial hemorrhage with a subdural hematoma measuring 11 millimeters in thickness and a subarachnoid hemorrhage. The combination of head trauma and blood-thinning medication created a medical emergency that ultimately proved unsurvivable.
The emergency department report noted that the "patient presents after a fall with head trauma while on blood thinner medication placing him at high risk for intracranial hemorrhage." Neurological specialists were consulted, but the family declined aggressive interventions. The resident died five days later on March 17, 2025, with his death certificate listing cardiopulmonary arrest and subdural hematoma as the cause of death.
Industry Standards for Fall Prevention
Current nursing home standards recognize that residents with dementia require individualized fall prevention strategies that address their specific risk factors and behavioral patterns. For a resident with this profile - combining moderate cognitive impairment, mobility issues, impulsive behavior, and multiple previous falls - standard protocols would typically include:
Environmental modifications such as lowering bed height, ensuring adequate lighting, removing obstacles, and using floor mats on both sides of the bed. The inspection found that while the resident had a fall mat on the left side of his bed, there was none on the right side where he could also exit.
Enhanced monitoring protocols, including more frequent safety checks, proximity to nursing stations, or continuous observation for high-risk periods. Staff interviews indicated the resident was "impulsive" and would attempt to get out of bed without using his call light, requiring "one-on-one monitoring."
Behavioral interventions addressing the underlying causes of fall risk, such as toileting schedules, pain management, and activities to reduce restlessness or confusion.
Quality Assurance Failures
The inspection revealed that the facility's Quality Assurance and Performance Improvement (QAPI) program failed to effectively analyze the pattern of falls and implement corrective measures. Federal regulations require nursing homes to use data-driven approaches to identify problems and implement solutions.
The facility's Administrator acknowledged the systemic failure, stating during the inspection: "we did not do enough fall interventions to keep Resident 1 safe from harm" and "it was our responsibility to keep residents safe."
The facility's own policies required that fall prevention plans be "reviewed and revised as appropriate" and stated that "if the resident continues to fall, the situation should be reevaluated to determine whether it would be appropriate to continue or change current interventions." Despite six documented falls over five months, no meaningful changes to the resident's care plan were implemented.
Regulatory Framework and Enforcement
This case highlights the critical importance of federal nursing home regulations designed to protect vulnerable residents. The facility was cited for violations of two key standards: failure to provide adequate supervision and fall prevention (F-tag 835) and failure to maintain an effective quality assurance program (F-tag 865).
These violations carry the classification of "minimal harm or potential for actual harm" affecting "few" residents, though the outcome in this case demonstrates how regulatory violations can have devastating consequences for individual residents and their families.
Additional Issues Identified
The inspection also documented other concerning patterns, including incomplete room identification systems and communication gaps between shifts. The resident's name was missing from the door nameplate following his final hospitalization, indicating potential issues with resident tracking and communication protocols.
The case underscores the particular vulnerability of residents with dementia who may not be able to advocate for themselves or follow safety instructions consistently. These residents require specialized care approaches that account for their cognitive limitations while maintaining their dignity and quality of life.
The facility's failure to adapt its approach despite clear evidence of ineffectiveness represents a fundamental breakdown in the continuous improvement process that federal regulations require. This tragic outcome serves as a stark reminder of the life-and-death importance of effective fall prevention programs in nursing home care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hanford Post Acute from 2025-04-04 including all violations, facility responses, and corrective action plans.
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