The August 20th incident at Fort Worth Transitional Care Center revealed systematic failures in fall prevention protocols. Licensed Vocational Nurse A had positioned herself outside the resident's room because she "liked to keep a closer eye on the resident." When she returned to her desk after helping another patient, she found the resident on the floor.
The mattress overlay had slid off the bed with the resident.
"One of the straps was not secured, which allowed the overlay to slide with the resident, when she slid off the bed instead of staying in place and preventing the resident from sliding out of bed," LVN B told inspectors during their September investigation.
The overlay was supposed to work differently. Built-in bolsters should have made it harder for the resident to slide out of bed. Instead, when the resident began moving toward her left side, the unsecured equipment moved with her.
LVN A had found the overlay unsecured before and had to secure it herself, she told inspectors. The facility's Director of Nursing confirmed during his investigation that the top right strap was not secured when the resident fell.
The resident was non-verbal. LVN A assessed her for injuries, checking for bruises and feeling for deformity. The resident didn't grimace during the examination, but her family member insisted she be sent to the hospital anyway.
Staff knew this resident was prone to falls. CNA C described her as someone who would "move about a little and work her way to one side of the bed or the other." CNA D was more specific: "No matter how often she was positioned in the middle of the bed, with pillows behind her, she would eventually end up on one side of the bed."
Both CNAs said fall-risk residents were listed in a binder at the nursing station and documented in the Kardex system. They rounded on these residents more frequently than others.
But the facility failed to follow its own fall prevention protocols for this resident. The Director of Nursing acknowledged that Resident #1 should have received a fall risk assessment in June 2025 for her quarterly review. She should have received another assessment immediately after her August fall.
Neither assessment was completed.
"He stated he did not know why neither one had been conducted," inspectors wrote.
The facility's Fall Prevention Program policy, dated August 15, 2022, required specific actions. Each resident must be assessed for fall risk upon admission. Nurses must complete fall risk assessments every 90 days and whenever a resident's condition changes.
A fall certainly qualifies as a condition change.
The Director of Nursing told inspectors it was the responsibility of nurses and CNAs to check the overlay and ensure it was properly secured. After the incident, he initiated in-service training on proper use of the overlays and resident neglect.
Only one other resident in the facility used the same type of mattress overlay as the resident who fell.
When inspectors observed the resident's mattress overlay two weeks after the fall, it was properly secured to the bed frame with three straps on each side. The facility had also replaced the original cover with "a different type of cover that was more secure than the previous one," according to LVN B.
The changes came after the damage was done. The resident had already experienced a preventable fall because staff failed to secure a single strap on safety equipment specifically designed to keep her in bed.
LVN A had been keeping closer watch on this resident for a reason. She positioned herself outside the resident's room because she recognized the elevated risk. But vigilance couldn't compensate for improperly secured equipment.
The facility knew this resident was a fall risk. Staff documented her tendency to slide toward the edges of the bed. They positioned pillows behind her and checked on her frequently. They listed her in their fall prevention binder and Kardex system.
They just didn't secure the one strap that would have prevented her mattress overlay from sliding out of bed with her.
The resident's family member understood the stakes better than the facility's staff. Despite LVN A's assessment showing no obvious injuries, the family insisted on hospital evaluation. They weren't willing to trust the facility's judgment about their loved one's condition after a preventable fall.
Federal inspectors found the facility failed to ensure residents received care and services to prevent accidents. The violation carried minimal harm but affected few residents - a regulatory classification that doesn't capture the human cost of lying on a nursing home floor because safety equipment wasn't properly secured.
The Director of Nursing's investigation confirmed what LVN A already knew from previous incidents: this mattress overlay had been found unsecured before. The pattern suggests systemic problems with equipment checks, not an isolated oversight.
Staff training followed the fall, but the resident had already experienced the consequences of inadequate fall prevention protocols. She had already been found on the floor next to her bed, her safety equipment having failed to perform its basic function because a single strap wasn't secured.
The facility's fall prevention policy promised individualized care based on each resident's risk level. For this resident, that meant more frequent rounding, positioning aids, and specialized mattress equipment. It should have meant properly secured straps.
Instead, she slid out of bed along with the overlay that was supposed to keep her safe.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fort Worth Transitional Care Center from 2025-09-03 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Fort Worth Transitional Care Center
- Browse all TX nursing home inspections