Paradigm at Faith Memorial: Delayed Emergency Care - TX
The resident fell on July 24. She arrived at the hospital with bruising and bleeding in her brain hours after the injury occurred, according to federal inspection records obtained by NursingHomeNews.org.
Federal inspectors classified the incident as immediate jeopardy to resident health and safety during a complaint investigation completed July 29.
The facility suspended LVN A pending investigation on July 25 based on a self-report to the state health department. The administrator and director of nursing didn't notify the medical director about the immediate jeopardy finding until July 26.
The inspection report identifies the resident only as "Resident #1" and provides no details about her condition or recovery. The facility transferred her to the hospital on July 24, the same day as the fall.
Federal inspectors returned July 27 and 28 to verify the facility had implemented emergency training for all nursing staff. They interviewed 11 licensed nurses over two days to confirm staff understood new fall protocols.
The director of nursing told inspectors she received education July 26 on conducting post-fall investigations, fall management, determining when to call 911, and monitoring neurological vital signs after falls. She said the facility created quick reference guides for each nursing station.
"If there were any changes in neuro responses, it was an acute change and it was an emergency," the director of nursing told inspectors during a July 27 interview.
The facility implemented new protocols requiring nurses to assess residents immediately after any fall, perform neurological checks every 30 minutes for up to 72 hours, and contact emergency services within one hour if doctors don't respond. Staff must now send residents to the emergency room immediately if they're on blood thinners and hit their head, or if they show signs of head injury including unequal pupils, loss of consciousness, cognitive changes, nausea, vomiting or headaches.
LVN B, who had worked at the facility five months, explained the new protocols during a July 27 interview: "An unwitnessed fall automatically needed neuro checks. They were to do assessments, vitals before they have been moved, and check for pain and any possible dislocations."
She said emergencies requiring immediate 911 calls included "an acute change in cognition, head injuries, suspected dislocation, pain upon movement, headaches, and suspected bleeding."
LVN C, who started June 5, told inspectors she would send residents to the hospital if they were on blood thinners and fell. "If they have major symptoms like bleeding, unresponsiveness, not alert and oriented, she would send them out because she did not want to take any chances."
The assistant director of nursing said nurses no longer had to contact physicians first in 911 situations. "She explained she would do what was best based off her nursing judgment."
Emergencies now included "any changes in head or skin, nonstop bleeding, headaches non-retractive, unstable vitals, changes in neurological conditions, and vomiting." If doctors didn't respond within 15 to 20 minutes, nurses were instructed to contact the director of nursing and medical director immediately.
LVN D, who started June 1, described her understanding of the new emergency criteria: "If they were on a blood thinner and hit their head, visibly bleeding profusely, broken limbs, unconscious, headaches, seizures, and if there was something she couldn't control."
The weekend care nurse explained that for unwitnessed falls, she would "count the vitals she did initially as her first check and start from there" for the required 30-minute neurological monitoring.
During the second day of monitoring, LVN E told inspectors that residents "who was bleeding, took blood thinners, vital sign out of normal range, unconscious, broken bones would be sent out 911."
LVN F said residents "who had a change in condition, unresponsive, on blood thinners/had bleeding, fractures would be sent out 911."
LVN G explained his protocol: "If they hit their head, we send the resident out 911 if there was bleeding, on anticoagulants, unresponsive and change of condition that was not at the resident's baseline."
All nurses interviewed confirmed they had received copies of the new quick reference guides and completed competency testing. The facility placed fall protocol binders at each nursing station for immediate reference.
The facility conducted an audit of all resident falls in the previous 30 days on July 26. The director of nursing and assistant director assessed each resident who had fallen to ensure no adverse effects had been missed.
An ad hoc quality assurance meeting was held July 26 with the medical director, administrator, director of nursing and assistant director of nursing to review the incident and new protocols.
Federal inspectors removed the immediate jeopardy finding July 28 at 7:09 PM after confirming all licensed staff had completed the required education and demonstrated competency on the new fall management protocols.
The facility remained out of compliance at an isolated scope with no actual harm but potential for more than minimal harm. Inspectors noted the facility must continue monitoring the implementation and effectiveness of their corrective measures.
Record reviews showed all staff completed education sessions between July 26 and 28 on quick guides for falls, change in condition communication, neurological checks, fall management, and fall investigations. All staff passed post-tests demonstrating knowledge of the new policies.
The inspection report does not identify what specific failures led to the delayed emergency response for the resident who developed the subdural hematoma, or whether the 2.5-hour delay affected her medical outcome.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Paradigm At Faith Memorial from 2024-07-29 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Paradigm at Faith Memorial in Pasadena, TX was cited for violations during a health inspection on July 29, 2024.
Federal inspectors classified the incident as immediate jeopardy to resident health and safety during a complaint investigation completed July 29.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.