Laurels of Gahanna: Chest Hematoma Goes Unmonitored - OH
Resident 109 was taking Apixaban, a blood thinner prescribed twice daily for atrial fibrillation, when the April 9 incident occurred at The Laurels of Gahanna. The medication increases bleeding and bruising risks.
During a bed-to-wheelchair transfer, the resident's knees gave out. The nursing assistant tightened the gait belt and guided her to the wheelchair to prevent a fall. But the belt had slid upward, constricting around the woman's chest and breast area.
The resident developed extensive bruising on the left side of her upper body. The bruise extended from her left underarm under her left breast, spanning from her waist to her shoulder, according to Assistant Director of Nursing 128.
Nobody measured the bruise. Nobody monitored its progression.
Staff initially thought the resident had suffered an unwitnessed fall. A certified nurse practitioner ordered an X-ray on April 10, then canceled it the next day after learning no fall had occurred.
The facility's interdisciplinary team met April 11 to review the bruising incident. They interviewed both the resident and the nursing assistant involved. The team recommended offering two-person assistance for all future transfers.
But they implemented no monitoring protocol for the injury itself.
"It was a big bruise and they would have noticed if it had gotten bigger," Assistant Director of Nursing 128 told inspectors during an August 7 interview. She acknowledged no formal monitoring occurred despite facility policy requiring it.
Two days after the team meeting, on April 13, the resident was hospitalized. A CT scan revealed a chest wall hematoma that required monitoring to ensure it wasn't spreading.
The nursing assistant had never reported the transfer incident to a licensed nurse, inspectors found. Assistant Director of Nursing 128 said she later educated the aide that such incidents must be reported immediately.
The facility's skin management policy, revised in August 2024, requires specific protocols when skin injuries occur. All skin tears must be evaluated, documented and treated based on physician orders. Licensed nurses must complete incident reports and monitor injuries weekly until healed.
None of this happened for Resident 109.
The assistant director defended the nursing assistant's actions during the transfer. "The incident happened quickly and she would not have wanted the resident to fall," she told inspectors. The aide had brought her to the resident's room to explain what occurred.
But the failure to monitor a significant injury on a patient taking anticoagulants violated federal care standards. The resident's blood thinner medication made proper wound monitoring especially critical, as such medications can cause internal bleeding and complicate healing.
Therapy staff had notified administrators about the bruising, but formal protocols weren't followed. The facility treated it as an isolated incident rather than implementing the systematic monitoring their own policies required.
Federal inspectors found the deficiency represented noncompliance related to three separate complaints filed against the facility. The violation affected multiple residents, not just the woman who developed the chest hematoma.
The resident had denied experiencing pain from the bruises when first examined April 10. But the extent of internal injury only became apparent when she required hospitalization three days later for the chest wall hematoma.
Assistant Director of Nursing 128 estimated the bruising covered a large area of the resident's torso. Yet no measurements were taken, no photographs documented the injury's progression, and no licensed nurse conducted the weekly monitoring the facility's own policy mandated.
The case illustrates how quickly routine care can turn dangerous for vulnerable residents. A standard transfer became a serious medical incident when proper techniques weren't followed and required monitoring was ignored.
The resident's hospitalization for chest wall hematoma monitoring could have been prevented with appropriate assessment and documentation of her injuries immediately after the gait belt incident occurred.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Laurels of Gahanna from 2025-08-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
THE LAURELS OF GAHANNA in COLUMBUS, OH was cited for violations during a health inspection on August 20, 2025.
Resident 109 was taking Apixaban, a blood thinner prescribed twice daily for atrial fibrillation, when the April 9 incident occurred at The Laurels of Gahanna.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.