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

One week after his admission to Fallbrook, a resident died on 6/12/09 due to medical complications after he fell and broke his hip at the facility. The resident suffered from dementia and had a history of fainting and frequent falls. Due to his high risk of falling, the facility planned to provide a low bed, a mattress on the floor and bed alarms. On 6/8/09, the resident's roommate advised staff that he had fallen out of bed onto the floor. The resident's bed was in the low position, but there was no mattress on the floor and no bed alarms. After tests revealed he fractured his hip, the resident was hospitalized and had hip surgery on 6/11/09. He died the next day due to medical complications of the hip fracture according to the coroner's report. The facility was cited because it failed to implement a plan of care to prevent injury from falls, which led to the resident's death.