The July 25 incident at Diversicare of Tupelo involved a resident admitted in 2015 with hemiplegia and hemiparesis following a cerebral infarction that affected his right dominant side. Federal inspectors found the facility's own care plan explicitly required two-person assistance for bed mobility and toileting.
CNA #1 told inspectors on August 11 that she was turning Resident #1 to provide incontinence care when "he reached over toward his bedside table and fell off the bed." She acknowledged the resident required assistance from one to two staff "depending on his mood" and confirmed she was required to review each resident's Kardex to know the required care.
The nursing assistant believed the Kardex indicated "one-to-two-person assist with bed mobility." But facility records told a different story.
Administrator interviews and record reviews confirmed that Resident #1's Kardex from July 22 through July 25 clearly specified "extensive assistance of (2) two for bed mobility and toileting." The administrator stated that "staff failing to do so resulted in the accident."
Two other certified nursing assistants confirmed the two-person requirement during inspector interviews. CNA #2, who had worked at the facility for about a month, said she was trained to follow the Kardex and stated Resident #1 "required two-person assistance since she had been working with him."
CNA #3 told inspectors that staff "are to follow the Kardex to provide appropriate care." She confirmed that Resident #1 "required two-person assistance for bed mobility and incontinent care because he is contracted."
The resident's most recent assessment, completed July 15 with an Assessment Reference Date showing current conditions, documented his care needs in the facility's Minimum Data Set. Section G, which covers Activities of Daily Living, coded both bed mobility and toileting as requiring "two-person physical assist."
The stroke had left Resident #1 with significant physical limitations affecting his dominant right side. His admission record from November 10, 2015 listed his primary diagnosis as "Hemiplegia and Hemiparesis following a Cerebral Infarction affecting the right dominate side."
Federal inspectors classified the violation as causing "actual harm" to the resident, indicating the fall resulted in injury beyond the facility's failure to follow its own care protocols. The inspection found that "few" residents were affected, suggesting this was not a widespread staffing problem but a specific failure to follow established safety procedures.
The incident reveals a breakdown in basic safety protocols at the 255105-licensed facility. Three different nursing assistants confirmed they understood the two-person requirement for this resident's care, yet CNA #1 proceeded alone anyway.
Diversicare of Tupelo's own documentation systems worked as designed. The Kardex clearly specified two-person assistance. The MDS assessment accurately captured the resident's functional limitations. The care plan reflected his stroke-related paralysis and need for extensive help with basic activities.
The failure occurred at the bedside, where a nursing assistant made a decision that contradicted written protocols and resulted in a preventable fall for a vulnerable resident who had been living with stroke-related disabilities for nearly a decade.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Diversicare of Tupelo from 2025-08-11 including all violations, facility responses, and corrective action plans.
