Hillsboro Health: Stroke Patient Falls, Bleeds Alone - OR

The resident, admitted in July with left-side paralysis from a cerebral infarction, was supposed to use a seatbelt and gait belt from home according to her care plan. Staff were directed to assist with the seatbelt each time she used her electric wheelchair.

On July 20, the resident slid out of her wheelchair onto the floor and suffered a bleeding leg laceration. She called emergency services herself and was transported to the hospital for evaluation.

Staff 12 told inspectors on August 8 that he could not get the resident's seatbelt around her because it was too small. He said he did not inform anyone about the sizing problem "because it was known."

The resident described the fall to inspectors: "She/he fell on the floor and her/his leg was bleeding. She/he yelled for help, but no one came." Scared and alone, she called 911 herself.

Staff 22, a licensed practical nurse who saw the resident during morning medication rounds, told inspectors she did not know if the resident was wearing a seatbelt when she fell. She was also unsure if seatbelt use was included in the care plan.

Administrator Staff 1 told inspectors on August 12 that he expected all staff to follow the care plan to prevent accidents.

The resident's care plan specifically required use of a "seat belt-gait belt from home" and directed staff to "assist resident with seat belt" when using her mobility device. The plan was established after her July admission for stroke-related left-side weakness.

Federal inspectors found the facility failed to ensure the resident received adequate supervision and assistance devices to prevent accidents. The violation placed residents at risk for injury due to accidents.

Staff 12's admission that the seatbelt sizing issue was "known" but unreported highlighted a breakdown in communication about essential safety equipment. Despite this knowledge, no alternative restraint was provided and no adjustments were made to prevent the resident from sliding out of her wheelchair.

The resident's experience of falling, bleeding, and calling for help without response exposed gaps in supervision protocols. Her resort to using her personal cell phone to summon emergency services underscored the absence of adequate staff monitoring.

The July 20 incident required hospital evaluation and treatment for the leg laceration. The resident's stroke-related mobility limitations made the fall particularly dangerous, as her left-side paralysis limited her ability to break the fall or quickly reposition herself.

Staff 22's uncertainty about both the care plan requirements and whether safety equipment was in use during the fall demonstrated inconsistent knowledge of resident care protocols among nursing staff responsible for medication administration and monitoring.

The administrator's statement about expecting care plan compliance contrasted with the documented failure to address known equipment problems or ensure proper safety device implementation for a vulnerable stroke patient.

The resident remains at Hillsboro Health & Rehabilitation Center, where the inspection found minimal harm but potential for actual harm due to inadequate accident prevention measures.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Hillsboro Health & Rehabilitation Center from 2025-08-12 including all violations, facility responses, and corrective action plans.

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