The incident at St. Margaret's Daughters Home occurred on August 20, 2025, just three days after the same resident had fallen and the facility failed to update safety protocols as required by its own policy.
Resident 72 was admitted with a documented history of falling. On August 17, the resident experienced a witnessed fall with no injury. But charge nurses never revised the care plan with new fall prevention measures before the end of their shift, violating facility policy that dates to 2002.
The Director of Nursing confirmed during inspection interviews that the care plan should have been updated immediately after the August 17 fall. The MDS Nurse agreed, stating the supervisor on duty failed to implement required changes before leaving that shift.
Instead, the resident's care plan remained unchanged from its May 19 revision date, with a next review scheduled for November 10. No new goals or interventions were added despite the fresh fall incident.
Three days later, the consequences became clear.
On August 20, a certified nursing assistant ignored the care plan's explicit requirement for two-person transfers. The CNA attempted to move Resident 72 from bed to wheelchair without assistance, resulting in another witnessed fall.
The resident's Activities of Daily Living care plan, which had finally been updated on August 19, clearly stated the person required "maximal assistance" and "the assistance of two person to transfer." The nursing assistant working that day either didn't read the updated plan or chose to ignore it.
The Director of Nursing confirmed during the inspection that Resident 72 was indeed care planned for two-staff transfers. She acknowledged that the fall prevention plan was not implemented when the CNA attempted the solo transfer.
Federal inspectors found the facility's Accidents/Incidents Policy, last revised in June 2002, specifically requires charge nurses and nursing supervisors to "initiate a plan of care change that was professionally warranted to ensure a resident's welfare and safety prior to the end of the shift."
The policy had been in place for over two decades. Staff simply didn't follow it.
This pattern of care plan failures affected one of four residents investigators examined for accident-related issues. But for Resident 72, the consequences were immediate and physical.
The inspection revealed a cascade of policy violations: first, the failure to update fall prevention measures after the August 17 incident, then the failure to implement existing safety protocols three days later. Each breakdown in the system put the resident at greater risk.
The facility's own documentation showed the resident required maximum assistance for transfers. The care plan was clear about the two-person requirement. Yet a single nursing assistant attempted the transfer alone, directly contradicting written safety protocols.
Federal regulations require nursing homes to develop complete care plans that meet all residents' needs, with measurable actions and timetables. When residents fall, facilities must immediately reassess and adjust those plans to prevent future incidents.
At St. Margaret's Daughters Home, that didn't happen. The August 17 fall came and went without any care plan modifications. The resident remained at the same level of documented fall risk, with the same transfer requirements, but no additional safety measures.
By August 20, when the CNA made the decision to transfer Resident 72 without help, the facility had already missed its first opportunity to prevent exactly this type of incident.
The Director of Nursing's acknowledgment during the inspection was straightforward: the care plan wasn't updated when it should have been after the first fall, and it wasn't followed when it mattered most during the second incident.
Resident 72 fell twice in four days, with the second fall entirely preventable if staff had either updated the care plan initially or followed existing transfer protocols.
The inspection found minimal harm to few residents, but for Resident 72, the facility's systematic failure to maintain and implement fall prevention measures turned a documented fall risk into repeated falling incidents within the same week.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for St. Margaret's Daughters Home from 2025-08-20 including all violations, facility responses, and corrective action plans.
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