The resident's representative discovered the multiple falls on August 14 during discussions about sending the patient home. A staff member casually revealed that the resident had fallen five times since admission, shocking the family member who had only been notified of one incident.
"I did not know he had been falling; I was here every day, I don't know why they didn't tell me?" the representative told state inspectors.
The stroke patient had been admitted with hemiplegia, paralysis affecting one side of the body. A June assessment showed the resident required substantial assistance for bed mobility and transfers, and had severe cognitive impairment.
Three falls occurred within a span of just over 24 hours in late June, inspection records show.
The first fall happened June 24 at 11:00 PM when the resident was found on the floor next to their bed with a scratch on their arm. Staff initiated neurological checks and took vital signs. The facility's incident report claimed both the physician and family were notified, with a conclusion note dated June 26 stating family notification had occurred.
Two nights later, on June 26 at 11:05 PM, the resident was discovered face down on the floor parallel to the bed. The initial incident report showed no notifications completed, though a note added the following day claimed the family and physician were notified.
Less than six hours later, at 4:45 AM on June 27, staff found the resident prone on the floor parallel to the bed again. This time, the report documented that a family member was notified at 12:47 PM that same day.
The resident was discharged home with their family member on June 27, according to progress notes.
Staff E, a Regional Clinical Nurse, told inspectors on August 20 that she had reviewed the incident reports and completed the conclusion sections. But she admitted she never actually contacted the family member to notify them of the falls.
"Staff E said they did not remember the details of the incident reports but assumed they asked the staff if the family had been notified," the inspection report states.
She acknowledged she would not have interviewed the licensed nurses assigned during the falls because the incidents occurred on night shift. The nurse said the expectation was that staff notify the resident's representative at the time of each fall unless they had specifically requested not to be contacted.
The discrepancy between documented notifications and actual family contact created a dangerous gap in communication. Federal regulations require nursing homes to immediately tell residents, their doctors, and family members about situations affecting the resident, including injuries and changes in condition.
State inspectors determined the facility's failure to properly notify the family representative placed residents and their families at risk of being unable to participate in care decisions, provide support, or ensure prompt medical treatment.
The pattern of falls raised additional concerns about the facility's ability to protect vulnerable residents. The stroke patient's cognitive impairment and mobility limitations made them particularly susceptible to injury from falls. Each incident represented a potential emergency requiring immediate medical evaluation and family notification.
Documentation showed the facility went through the motions of recording notifications without ensuring they actually occurred. The Regional Clinical Nurse's admission that she "assumed" staff had notified the family, rather than verifying contact, revealed a systematic breakdown in communication protocols.
For the family member who visited daily, the discovery of multiple unreported falls shattered their trust in the facility's transparency. They had been present every day, available for immediate notification, yet remained unaware their loved one was experiencing repeated dangerous incidents.
The resident's discharge home on June 27 came just hours after the third documented fall in the 24-hour period. Whether the family's decision to take their relative home was influenced by the facility's failure to disclose the pattern of falls remains unclear from inspection records.
The case highlighted how nursing homes can fail families even when they maintain constant presence and involvement in their loved one's care. Despite daily visits and obvious availability for communication, this family learned about critical safety incidents only through an offhand comment during discharge planning.
State inspectors cited the facility for violating notification requirements, finding that the breakdown in communication could have delayed necessary medical treatment and diminished the resident's quality of life. The family's shock at learning about five falls during what should have been routine discharge paperwork illustrated the human cost of the facility's failure to follow basic notification protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fir Lane Care from 2025-08-21 including all violations, facility responses, and corrective action plans.