MARTIN, TN - A 94-year-old resident at Vanayer Senior Living and Rehabilitation died four days after sustaining multiple leg fractures when she fell from her bed during routine care, according to a federal inspection report that cited the facility for failing to prevent the incident.
Fatal Fall During Personal Care
The incident occurred on January 14, 2025, when a certified nursing assistant was providing incontinence care to the resident, who had been weakened by a recent bout of influenza A. According to facility records, the aide turned the resident onto her side, then completely turned away to retrieve supplies from an overbed table. While the aide's back was turned, the resident slid off the edge of the bed and fell to the floor.
The fall resulted in devastating injuries: fractures to both femurs (thighbones) and a fracture to the left tibia (shinbone). X-rays confirmed the severity of the trauma, showing "acute appearing femoral and tibial fracture" in the left leg and "acute appearing femoral fracture" in the right leg. The resident died four days later on January 18, 2025.
According to the aide's written statement, "As I was turned I heard her start to slide off of the side [of the bed]. I tried to get to her in time to keep her on the bed but I wasn't quick enough. She fell on her bottom hitting her knee on the ground."
Multiple Safety Protocols Ignored
The inspection revealed a cascade of safety failures that contributed to the preventable incident. The resident had been classified as high-risk for falls with a score of 11 on the facility's fall risk evaluation, indicating she required enhanced safety measures. Her care plan specifically called for mechanical lift assistance with two staff members for transfers.
However, the aide who provided care that morning had not reviewed the resident's care plan or received a proper shift report. The aide later acknowledged she was unaware of the resident's weakened condition from recent illness. "When I went in there, she wasn't looking too good because she was sick, so I definitely should've gotten help," the aide stated during interviews.
The resident's family member emphasized the preventable nature of the accident, telling investigators: "I'm just so unhappy about the accident because it was avoidable... the only objection, with a patient who is 94, immobile from the waist down, [had] just gone through the flu, [was given] antibiotics for chest congestion, that instead of two CNAs to change her they had one and that's how the accident happened."
Medical Vulnerabilities Compounded Risk
The resident presented multiple medical factors that significantly increased her fall risk and vulnerability to injury. She had been diagnosed with Parkinson's disease, vascular dementia, hemiplegia (paralysis on one side of the body) following a stroke, and severe osteoporosis - a bone-weakening condition that makes fractures more likely and more severe.
Hand contractures - permanent tightening of muscles and tendons - limited her ability to grip the bed rails that were meant to provide stability during positioning. Most critically, she had been battling influenza A for several days before the fall, receiving antiviral medication and antibiotics for chest congestion. This illness had noticeably weakened her already limited physical capabilities.
Medical research demonstrates that acute illness significantly compromises an elderly person's physical stability and cognitive awareness. Influenza can cause muscle weakness, fatigue, and decreased alertness - all factors that increase fall risk. For residents with existing mobility limitations and cognitive impairment, even minor illness can dramatically reduce their ability to maintain safe positioning.
The facility's own staff recognized these heightened risks. The Licensed Practical Nurse who responded to the incident noted: "You could just tell she didn't feel good" and acknowledged being "shocked" when the fall occurred, as the resident had no previous history of falls during her two-year tenure at the facility.
Dangerous Equipment Contributing Factor
The investigation identified the resident's alternating pressure mattress as a significant contributing factor to the fall. These specialized mattresses, designed to prevent pressure sores by alternating air pressure, create an unstable surface that can increase fall risk when not properly managed.
The facility's root cause analysis revealed that "alternating air mattress edge is not as firm as regular mattresses" and "gives downward on edges when direct weight is applied." This instability meant that when the resident was positioned on her side, the mattress edge compressed under her weight, creating a slope that facilitated her slide toward the floor.
Multiple staff members acknowledged the safety implications of these mattresses. The aide involved stated: "It wasn't as firm [as regular mattresses], it was soft, you would put your hand on it, and it would go down." The facility's administrator noted that the alternating pressure mattress was identified as a contributing factor during their investigation.
Standard protocols for residents on such mattresses require additional safety measures, including mandatory two-person assistance for turning and repositioning. However, these protocols were not followed in this case.
Medication Storage Violation Identified
In addition to the fatal fall incident, inspectors documented unsafe medication storage practices that could have endangered wandering residents. During the inspection, investigators found an unsecured Breo Ellipta inhaler (a respiratory medication) left unattended on a resident's bed.
The resident stated the nurse had left the medication for her use and would return to collect it. However, facility policies explicitly prohibit leaving medications unsecured, and the resident had not been assessed or approved for self-administration of medications. The Director of Nursing confirmed this practice violated facility protocols and could have posed risks to the four residents identified as having wandering behaviors.
Systemic Communication Failures
The incident exposed concerning gaps in communication and care coordination. The aide involved in the fall had been reassigned from shower duties to floor care due to a call-off, without receiving proper orientation to the residents' needs or current conditions. She had not worked with this particular resident for approximately a month and was unaware of recent changes in the resident's health status.
Proper nursing home protocols require comprehensive handoff communication between shifts, including updates on residents' current health status, recent changes in condition, and specific safety requirements. The absence of this critical information directly contributed to the aide's decision to provide care alone rather than seeking the required two-person assistance.
Industry Standards and Required Protocols
Federal nursing home regulations mandate that facilities maintain comprehensive fall prevention programs tailored to each resident's individual risk factors. For high-risk residents like this 94-year-old woman, standard protocols include regular risk assessments, environmental modifications, staff education, and specific care interventions.
When residents require specialized equipment like alternating pressure mattresses, facilities must implement additional safety measures. Industry best practices call for enhanced supervision, mandatory two-person assistance for repositioning, and staff training on equipment-specific risks. These measures are particularly critical for residents with multiple risk factors including cognitive impairment, physical disabilities, recent illness, and bone fragility.
Care planning must be dynamic and responsive to changes in residents' conditions. When a resident develops acute illness, protocols require immediate reassessment of safety needs and adjustment of care interventions. Staff must be promptly informed of these changes to ensure appropriate care delivery.
Facility Response and Corrective Actions
Following the incident, Vanayer Senior Living implemented immediate corrective measures. The facility conducted a comprehensive review of all residents on alternating pressure mattresses and updated care plans to require two-person assistance for turning and repositioning. Staff received additional training on safe practices for residents using specialized mattresses.
The facility's Quality Assurance and Performance Improvement Committee conducted a root cause analysis and developed a monitoring plan including weekly audits for four weeks followed by bi-monthly reviews for two months. Knowledge checks and competency demonstrations were implemented to ensure staff understanding of the new protocols.
Additional Issues Identified
Beyond the major violations, the inspection documented concerns about incident documentation, noting that nursing progress notes failed to document the fall itself, only the subsequent medical treatment. This represents a gap in the facility's incident tracking and reporting systems that could affect future prevention efforts.
The investigation also revealed inconsistencies in staff understanding of safety protocols and the need for enhanced communication systems to ensure critical resident information reaches all caregivers, particularly when staffing changes occur unexpectedly.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ahc Vanayer from 2025-02-11 including all violations, facility responses, and corrective action plans.
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