The September 19 incident unfolded as nursing assistants passed responsibility for supervising the high-risk resident between themselves, each assuming someone else had taken over. By the time staff realized what happened, the resident had already walked the length of the facility and was lying injured on the front steps with his walker beside him.
The resident required constant supervision due to fall risk and "should therefore always be in staff's line of site," Nurse #1 told inspectors. Despite this requirement, no one working on the resident's unit knew he had left.
The chain of failed supervision began in the dining room. CNA #4 had been watching the resident but needed to care for another patient. She asked CNA #1 to take over supervision duties when she left the dining room.
CNA #1 said she knew the resident well and understood he required continual supervision due to his fall risk, even though she didn't typically work on his unit. She began supervising him but then had to leave to answer another resident's call light.
"As she was walking into another resident's room, she saw Resident #1 walking toward another CNA, so she figured Resident #1 would be supervised," according to the inspection report.
Nobody had.
By the time CNA #1 finished providing care to the other resident, the supervised patient had already left his unit. The resident had been agitated that evening because "he thought he had to go home to make dinner," Nurse #1 told inspectors.
Nurse #1 had asked CNA #1 to keep a close eye on the resident because she needed to administer medications to another patient at the end of the hallway. The resident "should not have been able to leave the unit unsupervised and walk all the way down the hall to the front entrance where he opened the door and fell," she said.
The fall was discovered when a visitor called out that someone had fallen. Nurse #5, working on a different unit, heard the commotion and ran to the front entrance.
She found the resident "laying on the top step in front of the main entrance with his walker next to him" and the facility receptionist standing nearby. Nurse #5 assessed the resident for injuries and paged other nurses for emergency assistance.
The resident suffered a pelvic fracture from the fall.
The Director of Nurses told inspectors that the resident required continual supervision for walking and "staff should have known where he was and what he was doing at all times." She said no staff members working on the resident's unit were aware he had left.
"Had Resident #1 been supervised, he would not have been able to walk off his unit alone, make it to the front entrance door, and fall, which resulted in a pelvic fracture," the Director of Nurses said.
The inspection found that multiple staff members had assumed someone else was providing the required constant supervision, creating gaps that allowed the resident to walk unsupervised through the facility. Each nursing assistant believed they had properly transferred responsibility to another staff member, but no one had actually taken over watching the high-risk resident.
Federal inspectors determined the facility failed to provide adequate supervision to prevent accidents, resulting in actual harm to the resident. The violation affected few residents but caused significant injury to the patient who required continual monitoring.
The resident's agitated state that evening, combined with his belief that he needed to go home to prepare dinner, likely motivated his attempt to leave the facility. His successful navigation from his unit through the hallways to the front entrance demonstrated how completely supervision had broken down.
The incident occurred despite facility policies requiring constant supervision for high-risk residents. The resident's walker accompanied him on his unsupervised journey through the facility, suggesting he had been mobile enough to cover significant distance before reaching the entrance where he fell.
The pelvic fracture represents a serious injury for any nursing home resident, particularly one already identified as having high fall risk requiring continual supervision.
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.