The June 6 incident at Woodbury Health Care Center left the resident hospitalized for three days with fractured tibia and fibula bones. She received narcotic pain medication 27 times over two weeks following her return, and told a psychologist she was "nervous" and had lost trust in facility staff.
Federal inspectors found the facility failed to follow its own safety protocols in multiple areas during a June survey, including incomplete care plans with blank intervention sections, missed bathing schedules, and inadequate cleaning of medical equipment.
The fall occurred when nursing assistant NA-B dismissed her partner and left the resident positioned on her left side while she retrieved barrier cream. The resident's care plan specifically required assistance from two staff members for bed mobility and toileting due to safety concerns.
"R68 was very particular so NA-B told NA-A he could leave, and she would call him back into the room when she needed him," according to the inspection report. NA-B stated she tried calling her partner back via walkie talkie but received no response.
When NA-B returned two to three minutes later, she found the resident on the floor. The resident told staff she "felt herself falling over the left side of the bed but could not stop herself."
Hospital records show the resident complained of left ankle and rib pain immediately after the fall. X-rays ordered that evening weren't completed until the following day, confirming the leg fractures. She was transferred to Woodwinds Hospital on June 7 for evaluation and pain management.
The facility's director of nursing acknowledged the care plan wasn't followed. He explained that after a similar fall by another resident in May, all bedbound residents were reviewed and it was determined this resident required two-person assistance specifically to prevent falls.
"She would not have rolled out of bed on her own, it was because she was left on her side alone," the director stated.
Incomplete Care Plans Leave Staff Without Direction
Inspectors discovered care plans for newly admitted residents contained blank sections where individualized goals and interventions should appear. One resident's care plan included template language like "TUB/SHOWER TRANSFER: dependent on assistance of # staff to complete" with numbers never filled in.
Another care plan listed focus areas but left them incomplete: "(Preferred Name) has Cognitive Loss/dementia or alteration in thought processes AEB [evidenced by] deficit's in memory/recall ability, judgement, decision making and thought process r/t [blank]."
The assistant director of nursing reviewed one resident's care plan and admitted: "There was like nothing done on there... It just didn't get done." She acknowledged the care plan was a critical tool that "tells you the picture [of them] and how best to care for them."
A licensed practical nurse examining another resident's generic care plan told inspectors: "Yes, I would expect the care plan to be more patient specific in the goals here. It should always say his name and be more person centered. This looks like it was put in generically and no one edited it."
Resident Goes Weeks Without Proper Bathing
One resident told inspectors she hadn't received "a shower or good, in-depth bed bath" since her admission three weeks earlier, calling the lack of bathing "always been a bug-a-boo since [I've] been living here."
The resident's electronic records showed only two body audit forms documenting bathing attempts: she refused on her admission day June 3, and received a bed bath on June 17. No other bathing was documented despite facility policy requiring weekly baths.
A nursing assistant acknowledged being unsure how often the resident was bathed, explaining they worked different shifts than when her scheduled Monday evening shower was supposed to occur. The assistant director of nursing couldn't locate documentation showing bathing had been offered between the recorded dates.
"We have some work to do," the nursing supervisor stated after reviewing the gaps in bathing records. She noted that proper bathing helps "reduce the risk of skin breakdown or other complications" especially since "older peoples' skin is very thin."
Medical Equipment Cleaning Failures
A resident using a non-invasive ventilation machine for sleep apnea told inspectors she had "never seen anyone clean" the device, though "it had looked like it needed to be cleaned for a while." Inspectors observed white and yellow substance covering the inside of the mask over multiple days.
The facility's treatment records showed daily documentation that the mask was cleaned with soap and water, but a registered nurse observing the machine stated "the mask could use some cleaning" and questioned why the night nurse had charted it as clean when it clearly wasn't.
Manufacturer guidelines require daily cleaning of the mask and weekly cleaning of tubing and water components to prevent bacterial growth. The facility lacked orders for comprehensive cleaning beyond the daily mask washing.
Medication Oversight Problems
The facility's consultant pharmacist flagged two medications in May that required physician review within 14 days under federal regulations. One recommendation involved a hospice resident receiving as-needed lorazepam for anxiety, and another concerned an antipsychotic medication being used for nausea.
The physician rejected one recommendation citing hospice status, but took no action on the second until June 26 during the inspection — 43 days after the pharmacist's warning. The consultant pharmacist emphasized that hospice status doesn't exempt facilities from the 14-day review requirement.
In a separate case, staff continued administering antifungal powder to a resident's groin area for three months after weekly skin assessments showed no signs of rash or infection. The resident's doctor stated the medication should have been discontinued when the condition cleared.
A trained medication aide applying the powder confirmed the resident's skin showed no rash but said he continued following the order since it lacked specific discontinuation criteria.
Trauma Care Gaps
One resident with post-traumatic stress disorder told inspectors: "No one here has ever asked me about triggers there are things that make my symptoms worse no one here has ever asked me about what those things are I think it would be helpful."
The resident's trauma screening from December identified multiple PTSD symptoms but showed she declined referrals. Her care plan acknowledged her trauma history but contained no individualized interventions for managing triggers or symptoms.
Multiple staff members, including nursing assistants and a licensed practical nurse, confirmed they weren't aware of any specific triggers for the resident. The facility's own policy requires care plans to "include specific interventions to eliminate or mitigate triggers that may cause retraumatization in trauma survivors."
The assistant director of nursing acknowledged the importance of identifying triggers, stating: "We don't want to agitate or upset them."
Positioning and Range of Motion Issues
Inspectors observed one resident repeatedly leaning over in bed with her head resting directly on a grab bar, despite therapy recommendations for proper positioning during meals. Staff made no attempts to reposition her or protect her head from the metal bar.
Another hospice resident with contracted hands was observed without required palm protectors over multiple days, despite therapy orders for the devices to prevent worsening contractures and maintain comfort. Nursing assistants were unaware of the palm protector requirement or range of motion program.
The facility's assistant director of nursing stated staff should be "comprehensively assessing" residents to find positioning devices they would tolerate and ensure their positioning preferences "should be assessed to make her choices in positioning as safe as possible."
The inspection, completed June 27, found the facility had corrected the two-person care issue through staff education following the resident's fall and hospitalization.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Woodbury Health Care Center from 2024-06-27 including all violations, facility responses, and corrective action plans.