Staff H, the nurse, admitted to federal inspectors she had "no excuses" for failing to examine Resident #2 while she remained on the ground at Fort Dodge Health and Rehabilitation. Three nursing assistants witnessed the incident and confirmed the nurse skipped the floor assessment.
The resident's nurse practitioner told inspectors he expected a complete head-to-toe examination before any movement, even if no obvious injuries were visible. He suspected all fractures occurred during the original fall.
Hospital records from July 18 documented Resident #2 had sustained a closed fracture of her right distal femur and a closed fracture of her left proximal tibia. The 83-year-old woman had severe cognitive impairment with a BIMS score of 6 and required substantial assistance with basic functions like toileting and transfers.
During interviews on August 7 and 8, three certified nursing assistants provided consistent accounts of the incident. Staff D said the nurse immediately directed staff to lift the resident without conducting any assessment. Staff F and Staff G both confirmed the nurse failed to examine Resident #2 while she remained on the floor.
When confronted by inspectors on August 8, Staff H acknowledged her failure. She confirmed she performed her assessment only after other staff had already moved the resident into her wheelchair.
The resident's medical history showed significant vulnerability. Her most recent assessment identified non-Alzheimer's dementia, age-related physical debility, back pain with nerve involvement, weakness, and reduced mobility. She was classified as non-ambulatory and required maximal assistance from staff.
Federal inspectors found a second pattern of neglect involving wound care documentation. Resident #5, who had diabetes, malnutrition, and lymphedema, developed multiple pressure injuries that staff failed to properly assess for weeks.
Weekly skin assessment forms revealed systematic gaps in care. On July 2, staff documented a 15-centimeter wound on the resident's right buttock that was dark purple and non-blanchable, plus a 12-centimeter area on her left buttock. By July 10, the facility failed to complete any assessment of the right buttock wound.
The resident developed additional areas of concern. Her left buttock showed a new 6.5-centimeter dark purple area, and her right gluteal fold presented a 10-centimeter purple wound. Staff described these injuries inconsistently and failed to provide complete measurements or staging.
Documentation gaps continued through July and August. The facility failed to assess any of the resident's documented skin areas on July 14, July 21, July 28, and August 6.
During an interview on August 26, facility leadership acknowledged widespread problems with wound assessment. The Corporate Clinical Market Leader, Director of Nursing, and Assistant Director of Nursing admitted that previous nurses had failed to properly evaluate skin conditions.
They reported the Assistant Director of Nursing had just started her first week as the full-time skin care nurse. The previous staff had consistently mis-coded wounds, making it impossible to track whether areas were pressure injuries, moisture-associated skin damage, or diabetic ulcers.
The facility couldn't "paint a complete picture" of what actually happened with residents' skin conditions, according to leadership.
A Quality Improvement Activity Sheet dated August 27 showed the facility had started a skin assessment project on August 4, acknowledging "incomplete wound assessment with incomplete weekly documentation."
The inspection was triggered by complaints and resulted in immediate jeopardy findings affecting few residents. Immediate jeopardy represents the most serious level of harm under federal nursing home regulations.
Resident #5's assessment had identified her as high-risk for pressure injuries. She already had one unstageable pressure injury described as deep tissue damage when the documented neglect began.
The failure to assess wounds properly meant residents with diabetes and other conditions that slow healing went weeks without appropriate monitoring. Dark purple, non-blanchable areas can indicate serious tissue death requiring immediate intervention.
For Resident #2, the consequences of the improper fall response became clear only after hospital evaluation revealed the extent of her injuries. Her nurse practitioner emphasized that thorough assessment might not reveal all damage, but proper protocol demanded examination before any movement.
The resident remained non-ambulatory and cognitively impaired, making her particularly vulnerable to additional injury from improper handling.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fort Dodge Health and Rehabilitation from 2025-08-27 including all violations, facility responses, and corrective action plans.
Additional Resources
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