Two days later, the resident complained of rib pain and was vomiting a coffee-brown substance. Only then did Thunder Care and Rehabilitation staff transport the patient to the emergency room, where doctors diagnosed internal bleeding.
Resident #9 had suffered a stroke and required total assistance from staff for basic activities including toileting, dressing, and bathing. Despite being cognitively intact, the resident was completely dependent on caregivers for physical needs.
The fall occurred sometime during the night shift. When nursing assistants found the resident on the floor, they simply returned the person to bed. No supervisor was notified. No incident report was completed. No assessment for head, neck, spine or extremity injuries was conducted, despite facility policy requiring immediate evaluation after any fall.
The resident remained in their room for two days before reporting left-sided pain and coffee-brown vomit to staff on September 21st. RN #1 sent the patient to the hospital that afternoon.
"They sent the resident out because they had complained about pain," RN #1 told inspectors. "They were not aware of the fall until the resident told them about it."
The resident returned from the hospital two days later with a diagnosis of gastrointestinal bleeding. Hospital records showed the patient had told emergency room staff they "rolled out of bed last night and hit left ribs."
Thunder Care's own policy, revised in March 2018, explicitly requires staff to "evaluate for possible injuries to the head, neck, spine, and extremities" immediately after any fall. The policy mandates obtaining vital signs "as soon as it is safe to do so" and notifying the attending physician and family "in an appropriate time frame."
None of these steps occurred.
The administrator discovered the cover-up only after conducting an investigation following the resident's hospitalization. During interviews, nursing assistants #4 and #5 admitted they had found Resident #9 on the floor and lifted the person back into bed. They told the administrator that LPN #2 was present when they moved the resident.
When confronted, LPN #2 acknowledged being in the room during the incident but had failed to complete any documentation or follow required procedures for fall assessment.
The administrator terminated LPN #2 on September 22nd for failing to complete an incident report and follow established protocols.
Inspectors found no documentation of the fall anywhere in the resident's medical record. The only evidence of the incident came from the resident's own account to hospital staff and the administrator's subsequent investigation of the cover-up.
The facility's policy specifically addresses situations where residents are "found on the floor without a witness to the event," requiring the same comprehensive assessment as witnessed falls. Staff were required to document all relevant details and ensure appropriate medical evaluation.
Instead, nursing assistants treated the incident as routine, returning a vulnerable stroke patient to bed without any medical assessment. The resident's subsequent hospitalization for internal bleeding suggests the fall may have caused the gastrointestinal injury that required emergency treatment.
RN #1's admission that they were unaware of the fall until the resident self-reported it to hospital staff reveals a systematic breakdown in communication and documentation. The nurse responsible for the resident's care had no knowledge that a fall had occurred, preventing any monitoring for delayed symptoms or complications.
The administrator's investigation uncovered not just the failure to assess and document the fall, but an apparent conspiracy among staff to conceal the incident. Multiple employees were aware of what had happened but failed to report it through proper channels.
Thunder Care houses 115 residents, many with complex medical needs requiring careful monitoring and prompt response to changes in condition. The facility's failure to follow its own fall assessment protocols put Resident #9 at risk for undetected injuries that could have proven fatal.
The terminated nurse's failure to complete an incident report prevented the facility from implementing additional safety measures or monitoring protocols that might have detected the resident's internal bleeding sooner. Two days passed between the fall and medical evaluation, during which time the resident's condition deteriorated without proper observation.
Resident #9's cognitive awareness made the cover-up particularly troubling. The person was alert enough to report their own fall to hospital staff when facility employees had failed to document or assess the incident properly.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Thunder Care and Rehabilitation from 2025-10-16 including all violations, facility responses, and corrective action plans.
Additional Resources
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