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.
At 9:56 that evening, caregivers came into the resident’s room and found him “supine (lying face upward) positioned in bed with rigor mortis (stiffening of the joints and muscles of a body that usually occurs a few hours after death) to his jaw, upper and lower extremities and lividity (reddish to purplish discoloration of the skin due to settling and pooling of blood) to his left flank area and hip.” Paramedics were called, and the resident was pronounced dead at 10:03 pm.
Remarkably, during the CDPH investigation, a nursing home LVN told the investigator that the resident actually had two falls on the day of his death, but that he was told by the administration not to document the second fall
The facility was issued an AA because it failed to:
- Implement safety measures and provide adequate supervision to prevent the resident, who was assessed as a high risk for falls, from falling and sustaining injuries.
- Develop a plan of care to address resident’s behavior of throwing himself to the floor to ensure the necessary care and supervision was provided to prevent injuries to the resident.
- Implement the resident’s care plan that stipulated the resident required a two-person assist with toileting.
- Implement and follow the policy and procedure requiring monitoring of residents after a fall when resident was found on the floor with injuries due to a fall.
All these violations presented an imminent danger that death or serious harm would result or there was a substantial probability that death or serious physical harm would result to the resident.
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