2200 Gramercy Drive, Sacramento, CA 95825
Citation Number: 030007455
Citation Date: 08/03/2010
Violation Date: 10/12/2007
On 10/12/07, a 97 year old resident fell from her bed to the floor while being cared for by a certified nursing assistant (CNA). She died four days later due to a head injury and compound neck fractures caused by the fall. According to the CNA, the resident rolled off the bed and fell to the floor face down after the CNA lowered her bed rail and then turned away from the resident to position her wheelchair. The resident's son questioned this explanation, stating "I did not ever see her (mother) move or turn herself." The facility did not train or discipline the CNA following the resident's fall and death. The facility was cited because its neglect caused the resident's death when it left her unattended without the side-rail in place or staff presence to prevent her from falling from the bed to the floor.