The incident at Terrace View Care Center occurred around 11 p.m. on September 27, when Licensed Vocational Nurse 1 discovered Resident 1 sitting on a floor mat beside his bed. The resident appeared to have been crawling out of bed, though no staff witnessed the actual fall.
LVN 1 observed "purplish green discoloration on the left side of Resident 1, around the size of the palm of a small adult hand." She helped the resident to the restroom and back to bed, then reported the incident to LVN 2, the assigned nurse for that resident.
But neither nurse followed the facility's own protocols for unwitnessed falls.
LVN 2 told inspectors she was "busy that night" and failed to notify the resident's physician about the fall and visible injuries. She also didn't conduct the neurological evaluation required by facility policy after any unwitnessed fall or head trauma incident.
The resident's representative wasn't contacted until 6:30 the next morning — seven hours after the incident. LVN 2 admitted she never documented this delayed notification.
LVN 1 confirmed to inspectors that she "did not report the incident to Resident 1's physician nor their representative and did not initiate the neurological evaluation."
When asked about the bruising, LVN 2 said she "did not remember LVN 1 reporting skin discoloration on Resident 1's left hip."
The facility's own policies, updated in September and October 2024, explicitly require neurological assessments following unwitnessed falls and any accident involving potential head trauma. The policies also mandate that staff follow up on fall-related injuries "until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved."
A subdural hematoma is a collection of blood that accumulates between the brain and the inner layer of the skull — a potentially life-threatening condition that can develop hours or days after a head injury.
The Director of Nursing acknowledged the multiple failures when interviewed by federal inspectors on October 9. She confirmed that Resident 1 was found on the floor with "purplish greenish discoloration on his left thigh" but could find no documentation that the physician or family representative had been properly notified.
"The DON stated the above incident was unwitnessed fall and Resident 1 was found with purplish greenish discoloration on his left thigh," inspectors wrote. "The DON further stated change in condition evaluation should have been initiated which included notification of physician and resident representative for Resident 1."
The nursing director also admitted that "a neurological evaluation should have been initiated for Resident 1 after the above incident."
Federal inspectors found that the facility's failure to follow its own fall protocols put the resident at risk. Without proper neurological monitoring, delayed complications from potential head trauma could go undetected. The seven-hour delay in physician notification meant the doctor couldn't provide timely medical assessment or treatment orders.
The inspection was conducted in response to a complaint filed against the facility. Inspectors determined the violations caused minimal harm but had the potential for actual harm to residents.
Progress notes from the incident show staff found Resident 1's bed in the lowest position with a floor mat beside it, suggesting the facility had already identified him as a fall risk. Despite these precautions, the resident still ended up on the floor with visible injuries.
The case highlights how communication breakdowns between nursing staff can compromise resident safety. LVN 1 reported the bruising to LVN 2, but LVN 2 claimed not to remember receiving that information. Meanwhile, both nurses failed to follow established protocols designed to protect residents from serious complications after falls.
For elderly nursing home residents, unwitnessed falls pose particular dangers. Without knowing exactly how they fell or what they hit, medical staff must assume the worst-case scenario and monitor for signs of internal bleeding, fractures, or brain injury that might not be immediately apparent.
The facility's policies recognize these risks, requiring ongoing monitoring and physician involvement after any fall with associated injury. But in this case, those safeguards failed completely, leaving Resident 1 without proper medical evaluation for hours after sustaining visible trauma.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Terrace View Care Center from 2025-10-09 including all violations, facility responses, and corrective action plans.