The March 28 incident at Redstone Highlands Health Care involved a resident with morbid obesity who needed help with balance and had cognitive communication problems. His care plan from May 2024 specifically required assistance from two staff for bed mobility and transfers.
Around 1:30 p.m. that day, Agency Nurse Aide 1 found the resident positioned awkwardly in bed and straightened him out, pulling him to the middle. She asked which side he preferred to roll toward for cleaning after noticing he had a bowel movement.
"She asked what side he rolls better toward, and he said to his left," according to the aide's statement to investigators. "The resident then reached for his bedside table and quickly rolled out of bed before she knew it."
The resident landed on his right side on the floor next to the bed. He told investigators the aide asked him to roll on his side, and "he started rolling to his left and kept going onto the floor. He landed on his right hip on the floor."
A nurse found the resident on the left side of the bed on the floor at 3:20 p.m. The resident said he fell and his hip hurt. The nurse assessed him before moving him back to bed, finding small scratches on his right elbow that were cleaned with saline. The physician, hospice, and family were notified.
X-rays revealed an intertrochanteric fracture just below the hip joint. The radiologist noted the clinical age was "indeterminate" but appeared either recent or an old healed fracture rather than acute.
By April 2, a physician evaluation confirmed the fracture was likely acute. The doctor found swelling and tenderness in the right hip during examination. "Likely an acute fracture," the physician wrote. "Will manage with pain medications."
The resident was under hospice care, and his family chose not to send him to the hospital for surgical intervention.
Agency Nurse Aide 1 later admitted her mistake to investigators during a March 31 conference call. "She stated that she should not have done it and feels horrible, but she thought she could handle it," according to the investigation report.
The aide said she had since been educated on the electronic medical record and the Kardex nursing worksheet that includes resident care requirements. "If she knew then what she knows now, this would not have happened," she told investigators.
The facility's investigation determined that the aide "did not following the resident's care plan" for two-person assistance with bed mobility. Administrator interviews on April 8 confirmed the aide failed to follow the care plan requirements.
The nursing home suspended the aide pending investigation results. After completing the investigation, administrators placed her on a "do not return to the facility list," permanently banning her from working there.
The facility implemented several corrective measures following the incident. All facility and agency staff received education on accessing and following resident care plans for bed mobility and transfers. The nursing home also began conducting audits to identify issues with care plan compliance for mobility assistance.
Results from these audits will be reviewed by the Quality Assurance Performance Improvement committee for additional corrective actions if needed.
The resident's care plan history showed ongoing fall risks. A September 2020 plan noted he was "at risk for falls related to the need for assistance with his balance." An October 2023 plan addressed communication problems related to cognition, directing staff to "ensure/provide a safe environment."
Federal inspectors cited the facility for failing to maintain a safe environment, resulting in actual harm to the resident. The violation was classified as affecting few residents but causing significant injury.
The case highlights the critical importance of following individualized care plans, particularly for residents with multiple risk factors including obesity, cognitive issues, and mobility limitations requiring specialized assistance protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Redstone Highlands Health Care from 2025-04-08 including all violations, facility responses, and corrective action plans.
Additional Resources
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