The incident at Stratford Specialty Care on May 15 began when Resident 13 took herself to the bathroom and had a bowel movement. Staff A, a certified nursing assistant, cleaned her up on the toilet and went to check the room number and call for assistance.
Resident 13 decided to transfer herself from the toilet to her wheelchair. Staff A saw the woman wasn't going to make it and assisted by lowering her to the floor to prevent a fall.
Staff A immediately found Staff C, the registered nurse on duty, who was passing medications down the center hall. Staff C said she was in the middle of giving medications, including insulin, and didn't want to make a medication error.
She made a decision. She would finish medicating her current resident before responding to Resident 13 on the bathroom floor.
"She acknowledged and reported that there was a delay in response," inspectors wrote. Staff C told investigators she decided to continue based on knowing Resident 13 had been lowered to the floor, didn't actually fall, and hadn't hit her head.
When Staff C finally secured her laptop and medication cart and reached Resident 13's room, a second staff member was present. The staff had already gotten Resident 13 off the floor and into her wheelchair.
Staff C verified that Resident 13 had not been assessed before she was moved from the floor. When asked how much time passed between being told about the incident and arriving at the room, Staff C estimated no longer than 10 minutes.
She assessed Resident 13, including vital signs and range of motion. Staff had notified her that Resident 13 had an injury on her back. Staff C said she didn't look at the woman's lower back at that time.
She planned to examine the back injury when Resident 13 was in bed. She never did.
"She stated she had forgotten and got busy," the inspection report documented. The day shift nurse evaluated Resident 13's back the following day and found an abrasion on her spine.
The facility's Director of Nursing told inspectors she would expect a nurse to complete a nursing assessment before any resident was assisted off the floor. She also expected the nurse to assess Resident 13's back after the fall.
The Director of Nursing acknowledged that when staff lower a resident to the floor, it's still considered a fall requiring documentation. She was aware there had been a delay in the nurse assessing Resident 13 after the fall.
"She said she expected the nurse to stop the medication pass and assess the resident after the fall," inspectors wrote.
The Director of Nursing was completing a disciplinary write-up for Staff C and provided investigators with a copy.
A facility corrective action form dated May 21 documented that Resident 13 had a witnessed fall on May 15 when Staff A lowered her to the floor. The form noted that Staff C's failure to respond timely wasn't reported to the Director of Nursing until May 20, five days later.
The form revealed that Resident 13's spine abrasion was discovered by the day shift nurse on May 16, the day after the incident.
The corrective action established that Staff C was expected to complete a full head-to-toe assessment, including skin checks and vital signs, on any resident who falls before the resident is moved from their position. If Staff C was completing medication rounds, she was expected to stop what she was doing and attend to the resident.
The facility's Change of Condition protocol, dating to January 2015, defines the purpose as providing care through nursing assessment, interventions and appropriate follow-up. The policy identifies a change in condition as any alteration from normal status, including accidents and incidents with or without injury.
Staff C's decision to prioritize medication distribution over fall assessment violated basic nursing protocols designed to identify potentially serious injuries before moving residents. The 10-minute delay and failure to examine Resident 13's back meant the spine abrasion went undetected for nearly 24 hours.
The incident occurred during an evening shift when staffing levels are typically reduced, highlighting the challenges nurses face balancing multiple critical responsibilities simultaneously.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Stratford Specialty Care from 2025-05-21 including all violations, facility responses, and corrective action plans.