Fallbrook Hosp. District Skilled Nursing Facility
325 Potter Avenue, Fallbrook, CA 92028
Citation Number: 080006541
Citation Date: 09/08/2009
Violation Date: 06/08/2009
Class: AA
Penalty: $ 90,000

Complaint(s): CA00191586

F323 Each resident receives adequate supervision and assistance devices to prevent accidents.

Resident 1 was assessed to be at high risk for falls upon admission to the facility. The facility failed to implement a plan of care to protect Resident 1 from falls. Resident 1 fell and sustained an intertrochanteric fracture of the left femur (a crack in the proximal femur) requiring surgery. Resident 1 died of medical complication from the left femur fracture.


Resident 1 was admitted to the facility on 6/5/09. The physician admission orders, dated 6/5/09, noted that Resident 1 had diagnoses that included dementia and syncope (a sudden but temporary loss of consciousness/fainting). The information sent by fax from the sending hospital (on 6/5/09 at 12:42) indicated that Resident 1 had been in and out of the hospital because of the syncopal episodes and a history of frequent falls.

On 6/16/09 the medial record of Resident 1 was jointly reviewed with Licensed Nurse 1 (LN1) who provided the initial assessment for Resident 1. LN 1 completed a Fall Risk Assessment Tool and an Admission Assessment Tool on the date of admission (6/5/09). The facility Fall Risk Assessment Tool has two categories: Low Risk (completed for all patients) and At Risk (completed for a fall score of 10 or greater) with the appropriate interventions listed under each section. LN 1 scored Resident 1 as a 14, indicating At Risk for falls. According to the Fall Risk Assessment Tool, the interventions for patients with a fall score of 10 or greater (At Risk) included clip alarm, pressure sensitive alarm, bed in low position and mattress on the floor.

According to the Admission Assessment tool LN 1 completed, Resident 1 was unable to use the call light due to cognition. On the evening of admission (6/5/09), LN 1 documented that Patient 1 had a history of syncopal episodes prior to admission and had fallen at home. LN 1 stated she was aware Resident 1 had a history of falls, and the facility automatically instituted fall precaution interventions for patients at risk to fall. LN 1 stated the interventions were: "low bed, mattress on the floor and bed sensor or tab alarms." According to LN 1 she had instructed the CNA's to institute fall precautions before the patient even arrived at the facility, because she "Knew he was a high risk." LN 1 further stated that she had not followed up with the CNA's to ensure they had implemented the appropriate fall interventions.

On 6/7/09 at 1:00 P.M., according to the nursing progress notes, Resident 1 had a syncopal episode while the CNA had attempted to get him up to the commode. The notes indicated that the resident's daughter was notified and had asked the staff to exercise caution with her father because he had a tendency to collapse even from a sitting position and it had often resulted in falls. The care plan was updated following the syncopal episode to include moderate assistance while transferring Resident 1 (with at least 2 people) and orthostatic blood pressures (a drop in blood pressure upon sitting/standing typically 20/10). Orthostatic blood pressures were taken on 6/8/09 and were as follows: 110/60 while lying down, 64/48 while sitting, and 72/44 after moving to the wheelchair.

Resident 1 fell on 6/8/09 at approximately 5:30 P.M. according to the nursing progress notes. CNA 1 was interviewed on 6/15/09 at 2:00 P.M., she stated Resident 1's roommate came out to the hall way and told her that he heard Resident 1 fall on the floor. CNA 1 stated she saw Resident 1 lying on the floor, on his left side, toward the bottom of his bed. CNA 1 recalled the resident's bed was in the low position, but there was no mattress on the floor and no alarms. CNA 1 stated the bed alarms and mattress were not instituted until after the resident's fall. The CNA called for help and 3 nurses arrived, RN 1, RN 2, and LN 1.

Interviews with RN 1 on 6/15/09 at 3:00 P.M. and RN 2 on 6/18/09 at 4:00 P.M. confirmed the fall, Resident 1's pain, the absence of alarms, and the absence of a mattress on the floor.

On 6/9/09 at 12:00 P.M. the physical therapist documented the addition of the pressure sensitive alarms, low bed and mattress to the floor following the fall. As well as the pain Resident 1 was experiencing and that the resident was not to be moved until an x ray was obtained.

According to the nursing documentation, the results of the x-ray were obtained at 8:15 A.M. on 6/10/09. The x-ray confirmed an intertrochanteric fracture (a crack in the left proximal femur). The physician called the facility with orders to send the patient to the hospital at 12:30 P.M. on 6/10/09.

On 6/10/09 at 2:15 P.M., Resident 1 was transferred to the hospital. A repair of the fractured left hip occurred on 6/11/09 at 11:49 A.M. Initially a spinal anesthetic (needle inserted into the spine to numb the patient from the chest down to the legs.) was attempted. Resident 1 was experiencing pain and the spinal was thought to be incomplete so a general anesthetic (a state of total unconsciousness) and artificial airway was used. Following the surgery Resident 1 experienced an episode of low blood pressure in the recovery room (86/52). Resident 1 was transferred to the heart monitored floor at 3:30 P.M. on 6/11/09. At 10:00 P.M. (6/11/09), Resident 1 began to experience fluctuations in his oxygen saturations (amount of oxygen in a person's blood). On 6/12/09 at 2:00 A.M., Resident 1's oxygen saturation was no longer registering on the monitor, his blood pressure had dropped and he began to experience heart rhythm disturbances. On 6/12/09 at 2:10 A.M., Resident 1 was pronounced dead. As this was a death occurring within 24 hours of admission the coroner's office was contacted.

According to the County of San Diego coroners report dated 6/12/09 the Cause of Death was listed as: "Medical complication of left hip fx (fracture)" Due To: "Fall" Contributing factors were listed as coronary artery disease, cardiomyopathy (enlarged heart), dementia, hypertension, prostate cancer and osteopenia (decrease in bone density).

The facility failed to implement a plan of care to prevent injury or harm from falls in a patient whom the facility determined to be at high risk for falls.

The violation of these regulations presented an imminent danger to the resident and was a direct proximate cause of the death of the resident.