The February 12 incident at Washington Center for Rehab and Healthcare violated the resident's specific care plan designed to prevent exactly this type of fall. Federal inspectors found the facility failed to follow basic safety protocols that could have prevented the injury.
Certified Nurse Aide #2 was changing Resident #128 when the person had another bowel movement. Instead of staying with the resident, the aide left the room to retrieve a clean pad from the linen cart in the hallway. When the aide returned, the resident was lying on the floor next to the bed.
The resident's bed was elevated at the time of the fall. Only one floor mat was in place, positioned on the side opposite from where the resident actually fell.
Registered Nurse #2 found the resident lying on their back on the floor, complaining of pain on the left side of their head. The nurse documented a visible hematoma and bruising on both knees from the impact.
Licensed Practical Nurse #5 was working nearby when the incident occurred. "They were working when they heard a noise from Resident #128's room, and the resident was found on the floor," according to inspection records. The nurse observed the resident lying with their head against the fall mat that had been placed on the wrong side of the bed.
The resident required evaluation by a nurse practitioner the following day. Nurse Practitioner #1's notes from February 13 documented the assessment was "for report of fall out of bed on 02/12/2025. Report hematoma left head but nothing visible at this time."
By the time of the medical evaluation, the head hematoma was no longer visible, though it had been clearly documented by nursing staff immediately after the fall.
Director of Nursing #1 conducted the facility's internal investigation and revealed multiple care plan violations that contributed to the incident. The investigation determined the resident's bed was not in the lowest position as required by their fall prevention plan.
Staff had used a Hoyer lift to place the resident in bed that evening, indicating the person required mechanical assistance for transfers and positioning. This detail underscored the resident's vulnerability and the importance of following safety protocols.
The investigation also revealed that while the resident had floor mats as part of their fall prevention plan, only one mat was in place and it was positioned incorrectly. The mat was on the side opposite from where the resident actually fell out of bed.
During the inspection, investigators attempted to interview Certified Nurse Aide #2 by phone on September 11. They left a message at 12:35 PM, but the aide never returned the call.
Director of Nursing #1 told inspectors during a September 12 interview that the aide had stepped out to get supplies from the linen cart across the hall. "They stated that the aide stepped out of the room across the hall to obtain a clean pad from the linen cart, and upon re-entering the room, the resident was lying on the floor next to their bed."
The nursing director's assessment the day after the incident found no skin abnormalities, but the initial documentation clearly showed the resident had sustained injuries from the fall.
Following the incident, facility management provided education to all staff on February 13. The training focused on "understanding the importance of reading care cards and the potential consequences of not adhering to them," according to inspection records.
Director of Nursing #1 and Assistant Director of Nursing #1 conducted the education session specifically addressing care plan violations. The facility recognized that staff had failed to follow the established fall prevention protocols for this resident.
The facility also completed a comprehensive audit to identify other residents who required floor mats and to assess overall compliance with fall prevention measures. This audit revealed the incident was not an isolated failure but part of broader compliance issues with safety protocols.
Management implemented additional measures to ensure residents remained safe and free from potential neglect when staff failed to follow established care plans. The facility developed specific procedures to prevent similar incidents.
Federal inspectors found the facility had taken sufficient corrective action by the time of their September survey. The corrective measures included the facility-wide education program, the compliance audit, and new procedures to ensure adherence to fall prevention plans.
The inspection classified this as an incident causing "actual harm" to the resident, though affecting only a few residents overall. The violation fell under federal regulations requiring facilities to ensure residents receive care consistent with their assessed needs and care plans.
The case illustrates how momentary lapses in following established safety protocols can result in preventable injuries to vulnerable nursing home residents. The resident's fall occurred during a routine care activity that should have been conducted safely according to their individualized care plan.
The aide's decision to leave the resident unattended in an elevated bed, combined with the incorrect placement of safety equipment, created the conditions that led directly to the resident's injuries and the facility's regulatory violation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Washington Center For Rehab and Healthcare from 2025-09-12 including all violations, facility responses, and corrective action plans.
Additional Resources
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