Gig Harbor Health: Fall Monitoring Failures - WA
State inspectors found that three residents at Gig Harbor Health and Rehabilitation experienced falls between July 17 and July 27, but nurses failed to complete the facility's own 72-hour monitoring protocol in every case.
Resident 2 fell three times in ten days. After the first fall on July 17, nursing notes show no documentation of alert charting for the required 72-hour monitoring period. The resident fell again on July 23. Nurses documented one alert charting entry at 1:42 AM on July 24, then stopped monitoring entirely.
Four days later, Resident 2 fell a third time on July 27 and was sent to the emergency room. Even after returning from the hospital that same day, nurses documented only routine daily notes with no fall monitoring through July 29.
Resident 3's case revealed similar gaps. After falling on July 21, the resident was sent to the emergency room on provider recommendation and returned to the facility that evening. Nurses completed alert charting on only three occasions over the next three days, missing multiple shifts during the critical monitoring window.
The facility's own nursing staff understood the requirements clearly. Staff F, a registered nurse, told inspectors during an August 4 interview that fall protocols included completing an incident checklist with head-to-toe assessment, pain assessment, and neurological assessment, followed by placing the resident on alert charting.
Staff G, a licensed practical nurse, explained the same day that after a resident falls, "they would place the resident on alert charting to monitor for any changes in behavior or medical condition."
The Director of Nursing Services made the expectations even more explicit. Staff B told inspectors on August 7 that residents should be placed on alert charting for 72 hours after any fall, with documentation completed every shift. Since nurses worked 12-hour shifts, this meant alert charting should occur at least twice daily.
"It is their expectation that alert charting should be completed at least twice a day after a fall," Staff B said.
Yet the nursing notes revealed systematic failures to follow these protocols. For Resident 2's July 17 fall, inspectors found no alert charting documentation whatsoever during the 72-hour monitoring period from July 16 through July 19.
After Resident 2's July 23 fall, nurses managed just one alert charting entry in the early morning hours of July 24, then abandoned monitoring entirely. Progress notes from July 23 through July 26 contained no further fall monitoring documentation.
The pattern continued with Resident 2's July 27 fall and emergency room visit. Nursing notes showed only routine "Daily Skilled Note" entries on July 28 and July 29, with no post-fall monitoring despite the resident's recent hospitalization.
Resident 3's monitoring proved equally inadequate. While nurses documented some alert charting on July 22, July 23, and July 24, the entries were sporadic rather than the systematic every-shift monitoring the facility's own policies required.
The inspection revealed that 911 was called and Resident 3 was sent to the emergency department, though the specific circumstances of this transport were not detailed in the available documentation.
Hospital emergency department notes from July 27 confirmed that Resident 2 was treated for a fall-related injury, underscoring the importance of the monitoring protocols that nurses had failed to implement.
The violations occurred despite clear facility policies and staff knowledge of proper procedures. Each interviewed nurse could articulate the correct post-fall monitoring requirements, yet the documentation showed consistent failures to execute these safety measures.
Alert charting serves as an early warning system to detect complications from falls, including potential head injuries, internal bleeding, or other conditions that might not be immediately apparent. The 72-hour monitoring window reflects the medical understanding that some fall-related complications can emerge hours or days after the initial incident.
For Resident 2, the failure to monitor properly occurred across three separate falls in rapid succession, suggesting a systematic breakdown in nursing oversight rather than isolated oversights.
The state inspection classified these monitoring failures as causing actual harm to residents, affecting few individuals but representing a significant breach of basic safety protocols that could have prevented recognition of serious complications.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Gig Harbor Health and Rehabilitation from 2025-08-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
GIG HARBOR HEALTH AND REHABILITATION in GIG HARBOR, WA was cited for violations during a health inspection on August 27, 2025.
Resident 2 fell three times in ten days.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.