The resident at Life Care Center of Kennewick had been admitted with a brain injury that caused loss of consciousness, stroke damage, and a history of falling. By June, their condition had deteriorated to severely impaired cognition and memory problems that required substantial assistance from staff for basic daily activities.
The facility's fall risk evaluation from March identified the resident as high risk. Their care plan spelled out specific interventions: anticipate their needs, keep the call light within reach, use mechanical lifts for transfers, and continue therapy for strength and balance.
But the most critical requirement came in a June revision to the care plan. Nursing assistants were instructed to ensure the resident stayed in supervised areas while up in their wheelchair.
On June 20, a nursing assistant found the resident on the floor of their room.
The facility's investigation revealed the cause: Staff B, described as a newly hired nursing assistant, had left the resident up in their wheelchair without supervision. The investigation concluded this was the root cause of the fall.
During the federal inspection in August, the Director of Nursing explained that all nursing assistants were trained to review the Kardex, a quick reference tool containing vital patient information and care directives. She said Staff B had recently completed orientation, which included training on reviewing care plans and the Kardex system.
New nursing staff received this training both during orientation and while working on the floor with experienced nursing assistants, she said.
Staff B should have reviewed the resident's Kardex before providing care, the director acknowledged.
The facility's own policy on person-centered care planning, updated in September 2024, required each resident to have a comprehensive care plan that addressed their medical, physical, mental and psychosocial needs. The policy emphasized that care plans must be implemented consistently across all shifts.
For this resident, that consistency broke down. The care plan explicitly required supervision while the resident was in their wheelchair in common areas. Instead, the resident was left alone in their room, where they fell.
The resident's medical history made the supervision requirement particularly crucial. Their brain injury had caused loss of consciousness, and stroke damage had interrupted blood flow to their brain. Combined with their history of falling, these conditions created a dangerous combination that required careful monitoring.
The comprehensive assessment from June showed the resident needed substantial help from one staff member for activities of daily living. Their severely impaired cognition and memory problems meant they couldn't reliably assess their own safety or call for help when needed.
The March care plan had already identified multiple fall prevention strategies. Staff were supposed to anticipate the resident's needs before problems arose. The call light was to remain within reach at all times. Mechanical lifts were required for any transfers to prevent staff from attempting manual assistance that could lead to drops or falls.
Therapy continued to work on the resident's strength and balance, but the June care plan revision showed these efforts weren't enough. The resident needed direct supervision whenever they were mobile in their wheelchair.
Federal inspectors found that this supervision requirement wasn't followed, placing the resident at risk for repeated falls and injuries. The failure affected not just this incident, but created ongoing danger for a vulnerable person whose brain injury and cognitive impairment left them unable to protect themselves.
The newly hired nursing assistant's failure to check the Kardex meant they missed critical safety information about a resident whose medical history demanded careful attention. Despite the facility's training protocols and the director's assurances about orientation procedures, the most basic step in resident care, reviewing their specific needs and restrictions, didn't happen.
The resident's fall became inevitable once supervision was removed. Their brain injury, stroke damage, severe cognitive impairment, and history of falling created a perfect storm that the care plan was designed to prevent.
Instead, a preventable fall occurred because a staff member didn't follow the written instructions meant to keep the resident safe.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Life Care Center of Kennewick from 2025-08-14 including all violations, facility responses, and corrective action plans.
Additional Resources
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