The incident at Hillsdale County Medical Care Facility involved a resident who scored 11 out of 15 on a cognitive screening test, indicating moderate impairment. Her care plan required assistance from one person for all transfers using a gait belt and two-wheeled walker.
On June 22nd at 2:01 PM, the resident was walking back from the bathroom with CNA D when the fall occurred. According to a progress note, the nursing assistant "let go of the gait belt to pull the personal chair closer." The resident immediately lost her balance and fell in the bathroom doorway, landing on her right side and hitting her head on the bathroom door.
CNA D admitted her mistake during a September interview with inspectors. She acknowledged using the gait belt and confirmed the resident had her walker, but said she experienced "a lapse in judgement and took her hand off the resident's gait belt."
The resident fell sideways, landing on her right shoulder.
Emergency room physicians diagnosed a closed, non-displaced fracture of the right distal clavicle. The resident required transfer to the local hospital for treatment.
When inspectors interviewed the resident in September, she remained dressed and seated in her wheelchair. She explained that she wished she could go home but had "experienced a fall at the facility that resulted in some setbacks." The woman described how she lost her balance while walking back to her recliner with staff assistance, sustaining the clavicle fracture.
The facility's Director of Nursing confirmed that staff should never release their grip during transfers. "The expectation would be to not remove your hand from the gait belt while transferring a resident," the director told inspectors.
CNA D received additional education following the incident. She acknowledged to inspectors that "she should never let go of a gait belt while transferring a resident."
Federal inspectors found the facility failed to prevent the fall during ambulation, citing inadequate supervision that resulted in actual harm. The resident's care plan specifically required one-person assistance with gait belt use for all transfers, a safety protocol designed to prevent exactly this type of incident.
The resident had been admitted to the facility with diagnoses including weakness and dementia. Her cognitive impairment score placed her in the moderately impaired category, making consistent safety protocols essential during any movement or transfer.
The bathroom transfer should have been routine. The resident was returning to her personal recliner, a familiar path she had traveled many times before with staff assistance. The two-wheeled walker provided additional stability, and the gait belt offered the nursing assistant secure control during the short walk.
Instead, CNA D's decision to reach for the chair while maintaining her grip on the resident created the dangerous moment that led to injury.
The fall occurred in the bathroom doorway, a confined space where the resident had no room to recover her balance. Landing on her right side, she struck both her shoulder and head, though the clavicle bore the brunt of the impact.
Hospital records confirmed the fracture was non-displaced, meaning the bone cracked but remained in proper alignment. While this represented the least severe type of clavicle break, the injury still required medical intervention and extended the resident's recovery time.
The incident highlighted how quickly routine care can turn dangerous when safety protocols are abandoned. Gait belts serve as the primary connection between nursing staff and residents during transfers, providing control and stability for people with cognitive and physical impairments.
For residents with dementia, consistency in safety measures becomes even more critical. Their cognitive limitations mean they cannot compensate for staff errors or react quickly to prevent falls.
The resident's September interview revealed the lasting impact of the incident. Months after the fall, she remained focused on the setback it had caused, connecting her injury directly to her continued stay at the facility rather than returning home.
CNA D's admission of a "lapse in judgement" acknowledged that she understood the proper procedure but chose to deviate from it in the moment. The subsequent education she received reinforced protocols she already knew but had failed to follow.
The Director of Nursing's statement confirmed that releasing the gait belt during transfers violated facility expectations and standard safety practices.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hillsdale County Medical Care Facility from 2025-09-15 including all violations, facility responses, and corrective action plans.
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