Santa Cruz HealthCare Center
1115 Capitola Road, Santa Cruz, Ca 95062
Citation Number: 070007755
Citation Date: 12/17/2010
Violation Date: 11/14/2010
On 11/14/10, a resident fell, fractured her neck, and died after getting out of her wheelchair unassisted and unsupervised in her room. The nursing staff found her on the floor in front of her bathroom with a large amount of blood from an apparent head wound. Paramedics were called and pronounced her dead a short time later. A mobility alarm that was supposed to alert staff that the resident was getting out of her wheelchair was not clipped to her clothing at the time of the fall. The resident had a history of repeated falls and injuries at the facility, including falls on 1/18/10, 7/20/10 and 8/21/20. Despite this history, the facility did not modify her care plan or try new interventions to protect her after the fall on 8/21/10. The facility was cited because it failed to provide supervision and assistive devices to prevent an avoidable accident. The facility did not evaluate the effectiveness of interventions to prevent falls and did not modify or replace interventions as necessary. These failures led to the resident's death.