Resident #101 had weakness on their left side from a stroke and needed maximum assistance for mobility. The patient was known to lean to the left while seated and required two staff members for bed mobility, according to interviews with facility staff.
But on the day of the fall, CNA #1 was providing shower assistance alone.
The nursing assistant told administrators that Resident #101 fell when she turned away to retrieve a towel. LPN #24 witnessed the incident. Both provided written statements to facility management after the fall.
The facility's investigation stopped there.
Administrators never examined whether the resident should have been left unsupported during the shower. They never reviewed the patient's documented need for assistance. They never questioned why a resident requiring maximum assistance was being bathed by a single staff member.
"The fall was not reported to the state agency because it was not an incident/injury of unknown origin," the Administrator told inspectors.
The facility's own documentation revealed the gaps in care that led to the fall.
Therapy Staff #29 explained that physical and occupational therapists were expected to communicate each resident's level of care needs to nursing staff. She defined moderate assistance as help from one person and maximal assistance "times two" as requiring two people.
LPN #3 recalled Resident #101's condition clearly. "The resident had weakness on the left side and sometimes was observed to lean to the left side while seated in the wheelchair," she told inspectors. She occasionally had to prop the resident up in the wheelchair and knew the patient required two staff members for bed mobility.
Yet the facility's Kardex system, which should have communicated these care requirements, failed completely for bathing assistance.
MDS Coordinator #11 reviewed Resident #101's Kardex Report during the inspection and acknowledged the bathing section was blank. He thought the resident would have required two people to transfer to the shower and one person to perform the actual bathing.
The Assistant Director of Nursing reviewed the same Kardex and confirmed the bathing assistance section was blank. "She was unsure how much assistance was required to provide bathing assistance for Resident #101," inspectors wrote. "She was unable to explain how staff would have been able to determine the number of staff required to assist the resident with bathing."
The ADON wasn't familiar with Resident #101 specifically, but she understood the risk. If a resident leaned in their wheelchair, she said, "the resident was at risk to fall if not supported on that side of their body."
CNA #34 explained how staff typically learned about resident care needs. She walked to the nurses' station and pulled out a printed document from a drawer. These reports were printed by the night shift nurse and kept at the station, she said. "They are shredded at the end of the day and that they were a working document, so there are no old copies."
RN #12, the Unit Manager for the Rehab Unit, was "unsure if the staff had a report sheet that they used to communicate resident care needs."
The communication breakdown had deadly consequences.
Federal inspectors found that CNA #1 turning her back and leaving the resident unsupported on their weak side "created a situation in which the resident was at risk for experiencing a fall." The facility's investigation "contained no evidence that the facility reviewed Resident #101's need for assistance or support while sitting."
The Administrator wasn't on duty when the fall occurred. When she returned to work after the weekend, she and the Director of Nursing spoke with CNA #1, who repeated that Resident #101 fell when she turned away for a towel. The Administrator obtained written statements from the nursing assistant and the witnessing LPN, then determined the fall was accidental.
No one questioned the care plan. No one examined whether proper assistance was provided. No one investigated why a resident with documented left-side weakness and maximum assistance needs was left alone, unsupported, during bathing.
The resident was hospitalized for a head injury that could have been prevented with proper staffing and supervision during a routine shower.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Rehab Center At Bristol from 2025-10-01 including all violations, facility responses, and corrective action plans.