Fort Worth Transitional Care Center

Observation on 09/03/25 at 10:55 AM of Resident #1's mattress overlay revealed it was properly secured to the bed frame with three straps on each side of the mattress.

Interview on 09/03/25 at 12:50 PM with CNA C revealed she was familiar with the residents, who were at risk for falls, and she rounded on them more frequently.

She stated the fall risk residents were also in a binder at the desk and on the Kardex (a documentation system that summarizes important details and quick access for essential patient data) for those not familiar with the residents.

She stated Resident #1 was known to move about a little and work her way to one side of the bed or the other.

Interview on 09/03/25 at 1:00 PM with CNA D revealed the nurses told the CNAs when there was a new resident, who was a fall risk, and the residents were also in a binder on the desk.

She stated those residents were rounded on more frequently.

She stated Resident #1 was particularly prone to sliding out of bed.

She stated 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.

Interview on 09/03/25 at 2:35 PM with the DON revealed the resident fall risk assessments were conducted on admission and then quarterly thereafter unless there was a fall, in which case an assessment would be completed at that time. He stated Resident #1 should have had a fall risk assessment completed in June 2025 for her quarterly assessment and definitely after her fall on 08/20/25. He stated he did not know why neither one had been conducted.

Interview on 09/03/25 at 3:41 PM with LVN A via telephone revealed on 08/20/25 she positioned herself outside Resident #1's room because she liked to keep a closer eye on the resident.

She stated she had returned to her desk outside Resident #1's room, after assisting another resident, and she saw the resident had fallen out of bed.

She called for help, and several staff came to assist her with the resident. LVN A stated when she found the resident she noted the mattress overlay had slid off the bed with her.

She stated she had found the overlay unsecured before and had to secure it.

She stated when she assessed the resident there were no bruises or obvious injuries.

The resident was non-verbal but did not grimace when she felt the resident for any injury or deformity.

When she notified the Resident #1's Family Member, the Family Member insisted the resident be sent to the hospital to be assessed for any injuries.

Record review of the facility's Fall Prevention Program policy, dated 08/15/22, reflected: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.2.

Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk 4 . g.

Complete a fall risk assessment every 90 days and as indicated when the resident's condition changes.

Facility ID: