The December 21 incident at Summerhill Elderliving Home & Care left the dementia patient with a 3-centimeter cut above her right eyebrow and blood on the floor beside her bed. Federal inspectors found that certified nursing assistant AA had turned the resident on her side to change her when the bed's protective bolsters slid off, sending the patient tumbling to the floor.
The resident's care plan specifically required two staff members for all turning and repositioning in bed. She was assessed as being at moderate risk for falls and had physician's orders for padded bolsters on both sides of her bed "to define the bed parameters and bring a sense of security related to fear of falling."
Licensed Practical Nurse HH documented finding the resident "on the floor beside the bed with blood on the floor" at 6:28 that morning. The patient was "responding normally to verbal and physical stimuli" but had sustained "a cut above the right eyebrow and a scrape to the right knee with noticeable bleeding in both areas."
Emergency room physicians closed the forehead wound with three sutures. The patient returned to the facility that afternoon with "three sutures to the right side of the forehead and a dressing wrapped around her head."
During the facility's investigation, nursing assistant AA admitted she was alone when she "had the resident turned on her right side to get changed" because "she had a bowel movement." AA wrote that "the sheet and the bolster started sliding off, causing the resident to fall off the bed."
The Director of Nursing confirmed to inspectors that "the bolsters were not secured to the bed, and R1 rolled off onto the floor" and that "CNA AA did not follow R1's care plan."
AA was terminated two days after the incident. The facility provided in-service education to nursing staff on "following the care plan and Kardex and checking bolsters on the bed."
Two days before the fall incident, another medication error sent a different resident to the hospital. Licensed Practical Nurse CC gave the wrong resident's medications to a patient with a history of stroke, causing him to faint in the bathroom.
LPN CC had wheeled the stroke patient to the medication cart and asked if his name was either his own last name or another resident's name. The confused patient incorrectly identified himself with the other resident's name. CC then looked at the photograph on the wrong medication record, which she said "resembled" the patient in front of her.
CC administered 14 different medications prescribed for the other resident, including heart medication amiodarone, blood thinner Eliquis, and blood pressure drugs carvedilol and hydralazine. The medications were signed out between 9:02 and 9:03 that morning.
Minutes after CC discovered her error, the patient collapsed in the bathroom during a bowel movement. Hospital physicians determined he experienced vasovagal syncope, a fainting episode that can be triggered by straining. However, they admitted him for 24-hour observation due to "medication error" and "polypharmacy" concerns after consulting poison control.
The patient remained hospitalized until December 24 after also testing positive for influenza.
CC wrote in her incident statement that she realized her mistake when she went to give medication to the other resident's roommate and found him "lying in his bed and was wearing clothing different from the resident who had identified himself" with that name earlier.
The RN Supervisor told inspectors that the stroke patient "jokes and can be silly" and was "probably joking when he told LPN CC his name" was the other resident's name. The supervisor couldn't explain why the nurse had offered two name options instead of simply asking the patient to state his name.
The facility's medication administration policy required staff to "verify the resident's identity before giving the resident his/her medications" through methods including "verbally asking the resident their name" and "checking the photograph attached to the medical record."
The Medical Director confirmed the medication error was "significant" but said the fainting episode was unrelated to the wrong medications, noting the patient had "a remote history of having a vasovagal episode."
Both incidents occurred within 48 hours during the holiday season, highlighting staffing and safety protocol failures that sent two residents to the hospital with preventable injuries.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Summerhill Elderliving Home & Care from 2025-01-28 including all violations, facility responses, and corrective action plans.
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