DUARTE, CA - A complaint inspection at Monrovia Post Acute revealed significant failures in fall prevention protocols that resulted in a resident experiencing two falls within an hour, leading to a displaced hip fracture requiring surgical intervention.
Inadequate Supervision Despite High Fall Risk
The violations centered around a resident with severe cognitive impairment and traumatic brain injury who was assessed as high risk for falls. Despite this designation, facility staff failed to provide adequate supervision when the resident exhibited increasing confusion and agitation on the night of June 23-24, 2024.
Records show the resident had been repeatedly getting out of bed unassisted throughout the evening. A certified nursing assistant (CNA) found the resident walking unassisted to the bathroom around 11 PM and had to redirect the confused resident back to bed multiple times. The CNA stated the resident "was very confused and could not sleep" and that staff had to "sit by [the] room door because [the resident] kept getting out of bed."
The first fall occurred at 1:20 AM when the resident got up unassisted for the third time that night. The CNA found the resident sitting on the floor against the wall near the window. Critically, despite this clear indication that existing fall prevention measures were inadequate, nursing staff failed to implement enhanced supervision protocols.
Critical Gap Between Falls Leads to Serious Injury
The most serious violation occurred in the 55-minute period between the first and second falls. Facility policy required that when a resident experiences increased confusion and repeated attempts to get out of bed, supervision should be escalated from every two hours to every hour, then to every 15 minutes, or even constant supervision as needed for safety.
At 2:15 AM, the resident fell again, this time sustaining a laceration to the head and what would be diagnosed as a displaced hip fracture. The roommate called for help when they heard the fall. The CNA found the resident on the floor with blood on her arm and gown, stating she "fell on something but was unsure of what it was."
This second fall resulted in a moderately displaced and mildly impacted fracture at the neck of the left femur. The resident required emergency transport to an acute care hospital and underwent hip replacement surgery on July 1st.
Medical Significance of Fall Prevention Failures
Hip fractures in elderly residents represent one of the most serious preventable injuries in nursing homes. These fractures carry significant risks including infection, blood clots, pneumonia, and increased mortality rates. For residents with cognitive impairment and existing mobility limitations, recovery is often prolonged and may result in permanent loss of function.
The failure to enhance monitoring after the first fall violated fundamental principles of injury prevention. Current geriatric care standards emphasize that fall risk is dynamic - when a resident experiences a fall, their immediate risk for additional falls increases substantially, particularly if contributing factors like confusion or agitation remain unaddressed.
Proper fall prevention protocols should have included immediate reassessment of the resident's condition, implementation of enhanced monitoring (potentially one-on-one supervision), environmental modifications, and consideration of interventions to address the underlying agitation and confusion that was driving the unsafe behavior.
Care Plan Failures and Policy Violations
The facility's own policies required staff to identify specific interventions based on fall risk assessments and to modify care plans when residents continue to fall despite initial interventions. The resident's care plan included general fall prevention measures but was never updated after the first fall to address the acute situation.
The Licensed Vocational Nurse (LVN) on duty failed to revise the care plan or implement additional interventions after the initial fall. Facility leadership confirmed that the nursing staff should have immediately escalated supervision and modified the care approach, but these critical steps were not taken.
The facility's Director of Nursing stated that due to the resident's "agitation and episodes of getting out of bed, the staff needed to increase supervision/monitoring from every two hours to every hour, elevate to every 15 minutes, or have [the CNA] stay with [the resident] as needed for safety."
Additional Issues Identified
The inspection also revealed documentation discrepancies, including no evidence that the LVN administered medication to the resident during the critical overnight period despite staff reports of medication being given. Multiple attempts to contact the LVN for clarification were unsuccessful.
The violations highlight broader systemic issues in fall prevention protocols and real-time clinical decision-making. The facility's policies contained appropriate guidance for fall prevention, but the implementation and communication of enhanced interventions during acute situations proved inadequate.
This case demonstrates how quickly preventable injuries can occur when clinical protocols are not properly executed, particularly for vulnerable residents with cognitive impairment who cannot effectively communicate their needs or understand safety instructions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Monrovia Post Acute from 2024-07-22 including all violations, facility responses, and corrective action plans.
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