Rosemead Healthcare Center

During a review of Resident 2's Change of Condition (COC)/Interact Assessment Form (SBAR, a sudden clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains), dated 4/19/25, the COC indicated on 4/19/25 Resident 2 suffered an unwitnessed fall, found on the floor inside bedroom. Resident 2 stated he slipped out of the wheelchair while leaning forward.

The COC further indicated the recommendation from the primary care physician was to perform neuro checks for 72 hours.During a review of Resident 2's Fall Risk (Morse) Assessment (a nursing tool that uses a scoring system to evaluate resident's risk of fall), dated 4/19/25, the assessment indicated Resident 2 scored a 35 (moderate risk for falling).During a review of Resident 2's Neuro Check List (NCL), the NCL indicated Resident 2 was monitored from 4/19/25 at 00:20 to 4/22/25 at 24:05.During a review of Resident 2's Change of Condition (COC)/Interact Assessment Form, dated 4/22/25, the COC indicated on 4/22/25 Resident 2 had a fall with a pain score of 3 out of 10 pain scale for the left parietal area [where the parietal lobes are located near the back and top of the head.

They are important for processing and interpreting somatosensory input].During a review of Nursing Progress Notes, dated 4/22/25, the notes indicated Resident 2 was found lying on the floor in front of his wheelchair at 22:30. A body check was completed and Resident 2 had a 2.5 x 2.5 cm bump on the left parietal area and complained of pain on a scale of 3 out of 10. Resident 2 stated he was sitting in his wheelchair and wanted to catch the urinal, but lost balance and was laying on the floor. Resident 2 was provided with an ice pack, and the MD was notified with no new order.During a review of Resident 2's Neuro Check List (NCL), the NCL indicated Resident 2 was monitored from 4/22/25 at 22:30 to 4/25/25 at 22:15.During a review of Resident 2's Fall Risk (Morse) Assessment, dated 4/22/25, the assessment indicated Resident 2 scored a 60 (high risk for falling).

During an interview on 8/13/25 at 9:40 a.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated the fall skin assessment by the treatment nurse is completed at the time of the fall or next day if it occurred at night.

When the resident is on an anticoagulant medication, or there is an unwitnessed fall, then it's automatic that the resident is sent out to the hospital unless the resident refuses to go. LVN 1 further stated the change of condition is completed by the nurse and the MD, RP/family are notified about the fall.

During an interview on 8/13/25 at 11 a.m. with the Director of Nursing (DON), the DON stated the facility does not have an IDT documentation note for Resident 2's falls that occurred on 4/19/25 and 4/22/25.

The DON stated the IDT met as a group, but the DON could not find any IDT note in Resident 2's medical record indicating the falls were evaluated and discussed by the IDT.

The DON stated he could only provide IDT notes for 3/31/25 (IDT after Resident 2 was admitted on [DATE]) and IDT notes for 6/26/25 (discharge planning for anticipated discharge on [DATE]).

The DON stated the process per the Fall Management Program Policy is the IDT meets within 72 hours of a fall and reviews the cause of the fall(s) and plans interventions and updates the care plan.

The DON stated the facility missed the opportunity to evaluate Resident 2's falls that occurred on 4/19/25 and 4/22/25 and update the care plan with interventions to mitigate or prevent future falls.During a review of the facility's current Policy & Procedure (P&P) titled, Fall Management Program, date implemented 10/1/23, the P&P indicated Post-Fall: The IDT-Falls Committee will meet within 72 hours of a fall.

The IDT-Falls Committee will review and document: 1) Summary of event following a fall; 2) Root cause analysis; 3) Referrals, as necessary; and 4) Interventions to prevent future falls.

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