The September 19 incident at Catholic Memorial Home revealed a breakdown in basic safety protocols for a resident whose care plan specifically required continual supervision for walking because of his high fall risk.
CNA #4 had been assigned to watch the resident during the evening shift and knew he needed constant supervision. She positioned herself in the dining room to monitor him as he stood up frequently throughout the evening.
When she needed to care for another resident, CNA #4 asked CNA #1 to supervise the fall-risk resident while she stepped away. But the handoff failed.
CNA #1, working outside her usual unit that evening, was familiar with the resident and knew about his fall risk. She had already stopped him twice from trying to reach the exits at the ends of the hallway. When she had to provide care for another resident, she saw him walking toward another CNA and assumed he would be supervised.
"She figured Resident #1 would be supervised," according to the inspection report.
By the time CNA #1 finished caring for the other resident, the fall-risk resident had already left the unit entirely.
The resident had been agitated that evening, telling staff he thought he needed to go home to make dinner. Nurse #1 had specifically asked CNA #1 to keep a close eye on him while she administered medications to another resident at the end of the hallway.
Despite these precautions, the resident made his way off his unit and all the way to the front entrance, where he fell and fractured his pelvis.
"No one [staff working on Resident #1's unit] was aware that Resident #1 had left the unit," the Director of Nurses told inspectors.
The facility's own policies made clear what should have happened. According to his care plan and resident profile, the man required continual supervision for walking, meaning "staff should know where Resident #1 was and what he/she was doing at all times."
The Director of Nurses confirmed that all CNAs are trained to check resident profiles for assistance levels. She said that had the resident been supervised as required, "he/she would not have been able to walk off his/her unit alone to the front entrance door and fall."
The Administrator agreed during interviews that if the resident's care plan indicated continual supervision for walking, "then he/she should have had continual supervision by staff."
A visitor ultimately discovered the fallen resident and had to find staff to help, according to the inspection report.
The incident occurred despite multiple staff members knowing the resident's high fall risk and need for constant supervision. CNA #4 knew he needed continual supervision and had been monitoring his frequent attempts to stand. CNA #1 knew his fall risk and had already intervened twice to prevent him from reaching exit doors. Nurse #1 knew he was agitated and had specifically requested additional supervision.
Yet somewhere in the chain of assumed responsibility, the resident slipped through unnoticed.
The facility's requirement for continual supervision meant staff should have maintained visual contact with the resident at all times. Instead, he was able to navigate off his unit, through the facility, and to the front entrance without anyone noticing his absence.
The fall resulted in a pelvic fracture, a serious injury that typically requires hospitalization and can lead to prolonged recovery periods for elderly residents.
Federal inspectors classified the violation as causing actual harm to the resident and cited the facility for failing to provide adequate supervision and assistive devices for residents who need help to prevent accidents.
The inspection was conducted in response to a complaint about the facility's care practices.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Catholic Memorial Home from 2025-10-14 including all violations, facility responses, and corrective action plans.