The incident at Devlin Manor Nursing and Rehabilitation Center began around dinner time on May 23, 2025, when staff first noticed the facial bruising on Resident #4. Multiple nurses were on duty, but confusion over who should handle the assessment led to a critical delay in medical care.
GNA #20 told inspectors that staff "did not know what happened to Resident #4's face" when they discovered the bruising that evening. The resident was independently ambulatory and could move around without assistance.
LPN #4 was working as a nursing assistant that shift and assumed LPN #9 would assess the resident and contact the physician. But LPN #9 later told the unit manager she didn't remember seeing or hearing anything about the facial bruising on May 23.
Nobody called the doctor that night.
The next morning, RN #18 noticed the bruising and finally notified the physician on May 24. When asked about the injuries, the resident initially denied falling but later admitted, "I fell yesterday," though couldn't provide any details about what happened.
The unit manager explained the breakdown to inspectors: "The nurses usually took care of only the residents on their assigned hall, but one of the nurses should have done something on May 23 when the bruising was first identified."
During the delayed investigation, more confusion emerged. LPN #4 believed she had reported the bruising to LPN #9, who she thought had already assessed the resident and notified the physician before LPN #4 took over LPN #9's hall duties. As a result, "nothing related to Resident #4 was passed on in report" during the shift change.
The Director of Nursing received a call about the bruising on May 24 and immediately instructed staff to interview everyone who had worked with the resident. Her investigation revealed that the bruising had actually been reported to both LPN #4 and RN #10 the previous day, but neither had taken action.
The facility's physician was clear about expectations when interviewed by inspectors. He stated that nursing staff should "report to a provider of a possible head injury right away." His medical group should have been contacted about the facial bruising on May 23 "instead of the next morning."
More critically, the doctor said the resident "should have been sent to the emergency room right away to rule out any further injury beyond bruising."
The 24-hour delay meant the resident went an entire night without proper medical evaluation for what could have been a serious head injury. Facial bruising, particularly around both eyes, can indicate trauma that requires immediate assessment to rule out brain injury or other complications.
The Administrator told inspectors he expected nursing staff to notify providers "in a timely manner when they identified a resident's change in condition." That expectation clearly wasn't met.
Following the incident, the Director of Nursing provided re-education to all nurses on identifying changes in resident condition and improving communication between nursing staff. The training focused on ensuring medical needs are addressed promptly rather than being lost in shift changes and assumptions about who is responsible.
The inspection found that some residents were affected by the facility's failure to ensure timely physician notification of potential injuries. Federal regulations require nursing homes to immediately consult with physicians when residents experience possible injuries, particularly those involving the head and face.
The case highlighted a dangerous gap in the facility's communication system. When multiple nurses are on duty, unclear protocols about who handles assessments and physician notifications can lead to critical delays in care.
RN #18 ultimately began neurological checks on the resident after finally reporting the bruising, but this monitoring should have started immediately when the facial trauma was first discovered. The delay potentially put the resident at risk if there had been underlying brain injury from the fall.
The resident's ability to walk independently may have contributed to staff initially underestimating the severity of the situation. However, even ambulatory residents can suffer serious head injuries from falls, making immediate medical assessment essential regardless of their mobility level.
The facility's investigation revealed a pattern of assumptions and miscommunication that left a potentially injured resident without proper medical attention for hours. Each nurse assumed someone else had handled the required notifications and assessments, while the resident spent the night with untreated facial trauma that the physician later determined warranted emergency room evaluation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Devlin Manor Nursing and Rehabilitation Center from 2025-09-12 including all violations, facility responses, and corrective action plans.
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