Resident #3 at Adel Acres fell during the overnight shift on August 11, 2025. Staff documented the incident but failed to perform the comprehensive evaluation required by the facility's own fall management policy.
The resident's pain became apparent to multiple staff members throughout the morning. A therapy worker noticed the resident complaining of left hip pain. A certified nursing assistant observed the resident couldn't bear weight on the right leg and was experiencing right hip pain.
Despite these clear warning signs, no one conducted the full assessment mandated after every fall.
Staff O, interviewed by inspectors on October 14, described what should happen: "When a resident falls do a full head to toe assessment, vital signs, check range of motion, look for rotation of legs, and document all." She explained staff must "observe everything on the resident, do neuro checks per policy, complete and document a fall follow-up every shift for 72 hours."
But that didn't happen for Resident #3.
Staff O stated she didn't recall any nurse asking her to assess the resident on August 11. She came to work around 7:00 AM and spent time with the Director of Nursing trying to figure out whether the resident had experienced one fall or two falls during the night shift.
The confusion over basic facts about the incident reflected the inadequate response. While staff debated how many times the resident had fallen, the person remained in pain with an undiagnosed fracture.
Staff O eventually assessed the resident later that morning alongside the Director of Nursing. Only then did they notice bruising on the resident's right hip.
The Director of Nursing told inspectors she wasn't aware of the resident's falls until she arrived at work on August 11. She first learned about the resident's pain and inability to bear weight at what she believed was the 9:30 AM morning meeting.
"Therapy told her the resident was complaining of pain and the left hip, staff told her was the resident's right hip and he was not bearing weight on his right leg," according to the inspection report.
Even at this late stage, there was confusion about which hip was injured.
The Director of Nursing finally called the physician, who ordered an X-ray. The results revealed what should have been discovered hours earlier through proper assessment protocols.
Hospital records show Resident #3 was admitted on August 11 with "a mildly displaced right intertrochanteric (hip) fracture in moderate varus malalignment." The resident required hip replacement surgery.
The facility's own Healthcare Fall Management Program, dated October 2024, explicitly requires follow-up documentation "every shift for at least 72 hours after the fall" including neurological checks, vital signs, pain assessment, and range of motion evaluation.
None of this happened in the crucial hours after Resident #3's fall.
Staff O acknowledged during her interview that if a resident's "assistance requirements increased and complaining of pain she would notify the physician and not move the resident around, with all assessments documented."
She also stated that when residents report pain and require increased assistance, staff should "do a full assessment, notify the physician for possible x-rays, and provide pain medication if available."
These protocols existed on paper but failed in practice.
The resident's suffering was entirely preventable. Proper assessment immediately after the fall would have identified the injury and prompted immediate medical attention. Instead, the resident endured hours of pain with a fractured hip while staff remained confused about basic details of the incident.
Federal inspectors found the facility failed to ensure residents received proper treatment and services to attain the highest practicable physical well-being. The violation affected few residents but caused actual harm.
The Director of Nursing's admission that she wasn't aware of the falls until the next morning raises questions about communication protocols during shift changes. Critical information about resident injuries apparently wasn't being transmitted effectively between nursing staff.
By the time the physician arrived at the facility and reviewed the X-ray results, precious hours had been lost. The resident was transported by ambulance to the hospital, where the hip replacement surgery took place.
Resident #3's case illustrates how procedural failures can compound into serious medical consequences. A fall that should have triggered immediate comprehensive assessment instead led to prolonged suffering and more extensive medical intervention.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Adel Acres from 2025-10-16 including all violations, facility responses, and corrective action plans.