Santa Fe Heights nursing home in Compton was issued an AA citation by the California Department of Public Health (CDPH) on October 16, 2020 after a resident was seriously was killed in a fall that went unnoticed by staff.
The injured resident had four falls in four consecutive months despite being assessed by nursing home staff at being at high risk for falling. After the fourth fall, the resident was found on the floor unresponsive and without vital signs. An investigation by CDPH revealed that Santa Fe Heights failed to implement safety measure and provide adequate supervision to the resident and failed to develop a plan of care to address his growing fall risk.
Nursing notes revealed that at the time of the last (and fatal) fall, the resident was found by a CNA on the floor at 2:45 pm after attempting to transfer from the toilet. He reportedly hit his head in the fall and was promptly returned to bed without a neuro-check being performed. Despite his obvious signs of injury, including a laceration on his head, there was no assessment for injury, nor any follow up.