The resident, identified only as R1, complained of "10/10 pain in right arm" during morning medication rounds on August 23rd. She told the registered nurse that her arm "was hit on the door frame on accident" the previous evening when CNAs were transferring her to the bathroom using an EZ stand lift.
R1 has right-sided paralysis from a brain hemorrhage, along with impaired mobility, chronic pain, and arthritis. The injury occurred around 9:15 PM on August 22nd, but nursing staff working that shift never learned about it.
Two CNAs were involved in the transfer. One later wrote that the resident's "right arm was brushed against the door due to easy stand barely fits and resident arm was hanging." The resident said it hurt but told them "it was fine."
The second CNA described how the resident's "right arm hit the frame of the door" while being pushed into the bathroom. This assistant apologized and "repeatedly asked if she wanted an ice pack, and she said no."
Both CNAs acknowledged the incident occurred. Neither reported it.
Facility policy is explicit about accident reporting. The Resident Incident/Accident Reporting Protocol, reviewed in January 2025, states that "all incidents and accidents (regardless of how minor they may present) must be reported to the Charge Nurse immediately upon discovery with a completed applicable event report and communicated to the oncoming shift."
The resident spent the night in pain. Only when she complained to the registered nurse during morning medication rounds did staff begin investigating what happened.
Federal inspectors found no documentation of the August 22nd incident in R1's medical record. The facility gathered witness statements from both CNAs only after the resident reported her pain the following morning.
Director of Nursing B confirmed to inspectors on September 15th that the CNAs "did not report the incident to the nurse working with R1 at the time of the incident, or the charge nurse, or to the oncoming shift, as the policy directs."
The failure represents more than a paperwork oversight. R1's complex medical conditions - including her stroke-related paralysis and chronic pain - made prompt evaluation of any new injury critical. Instead, she endured hours of severe pain while nursing staff remained unaware that an accident had occurred.
The EZ stand equipment that caused the problem barely fit through the bathroom doorway, according to one CNA's statement. This suggests the facility was using transfer equipment in a space too narrow for safe operation, creating predictable collision risks for residents with limited mobility.
Both CNAs apologized to the resident immediately after the incident. One offered ice. But their response stopped there, leaving supervisory staff with no knowledge that an accident requiring medical assessment had taken place.
The inspection found that only one of eight sampled residents experienced inadequate supervision to prevent accidents. But for R1, that lapse meant a night of untreated pain after what should have been a routine bathroom transfer.
Federal inspectors cited the facility for failing to provide adequate supervision to prevent accidents and ensure proper reporting when incidents occur. The violation received a "minimal harm or potential for actual harm" rating, affecting few residents.
The case illustrates how communication breakdowns can compound physical accidents in nursing homes. R1's injury might have been minor and unavoidable given the tight bathroom space. But the failure to report it meant she received no immediate medical evaluation or pain management when she needed it most.
R1 continues living at Mulder Health Care Facility with her multiple medical conditions, including the chronic pain that made her overnight suffering particularly acute.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mulder Health Care Facility from 2025-09-16 including all violations, facility responses, and corrective action plans.