The incident occurred at M I Nursing & Restorative Center on September 3, 2025, when CNA #2 found the resident soiled and attempted to roll them to their left side without assistance. She heard the resident's right arm "crack" during the repositioning.
The resident's daughter received a call from the overnight nurse at approximately 3:00 A.M. informing her that her parent's arm was broken and they were being sent to the emergency room. The daughter said she was confused because she believed the resident required two staff members for any type of care, but the nurse told her a CNA had provided care alone.
When the daughter asked why two people weren't available to provide care, the nurse couldn't provide an answer.
CNA #2 admitted during a telephone interview that she knew the resident required two people for care but decided to provide care alone anyway. She said she had been caring for the resident's roommate and noticed the resident was soiled when leaving the room. Though the resident wasn't on her assignment, she decided to provide incontinence care.
The nursing assistant said she attempted to ask for help from the other CNA on duty, but he was busy. She didn't ask the nurse on duty for assistance. She also admitted she didn't review the resident's care plan or Kardex information before her shift, despite having the ability to access this information.
CNA #1, who serves as the resident's primary daytime nursing assistant, confirmed the resident is dependent for all care and requires two staff members for all toileting and bed mobility tasks. She said two CNAs are required because the resident is too heavy for one person to move safely.
The overnight nurse, Nurse #1, said all staff can access and view resident care plans or Kardex information to see the level of care required. He confirmed the resident has always required two staff for personal care and bed mobility tasks because of their weight and for the safety of both staff and resident.
Nurse #1 said CNA #2 never asked him to assist her, though he helps all CNAs during his shift when needed or asked. He emphasized that one person cannot safely provide care to this resident alone.
The Director of Nursing confirmed that CNA #2 observed the resident to be soiled in bed, couldn't find help from the other CNA, and provided care alone. She said CNA #2 heard the resident's arm "snap" while providing care and immediately got the nurse for help.
The resident was sent to the hospital after assessment, and the nurse practitioner and health care proxy were notified of the injury.
The Director of Nursing acknowledged she never asked CNA #2 whether she had requested help from the nurse and was unsure if this had occurred. She said CNA #2 was relatively new to the floor and wasn't familiar with the residents.
Despite the Kardex being available for staff to review, the Director of Nursing confirmed CNA #2 didn't review this information before starting her shift or providing care to the resident. She stated that CNA #2 didn't follow the plan of care written for the resident.
The inspection found that the facility failed to ensure services were provided by qualified persons in accordance with each resident's written plan of care. The violation resulted in actual harm to the resident, who suffered a broken arm that required emergency medical treatment.
The resident's daughter expressed confusion about why proper safety protocols weren't followed, particularly given her understanding that her parent required two-person care for all mobility and personal care tasks. The incident occurred despite clear documentation in the resident's care plan specifying the need for two staff members.
The nursing assistant's decision to proceed with solo care, despite knowing the safety requirements and being unable to locate immediate help, directly resulted in the resident's injury. Her admission that she was aware of the two-person requirement but chose to ignore it highlights a serious breakdown in following established care protocols designed to protect vulnerable residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for M I Nursing & Restorative Center from 2025-10-02 including all violations, facility responses, and corrective action plans.
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