The confusion emerged when inspectors questioned multiple staff members about fall response procedures following an incident involving Resident #1, who was found bleeding on the floor in a prone position.
The Assistant Director of Nursing told inspectors she would check a fallen resident's range of motion first. If the assessment showed any changes or decreases in range of motion, she said she would not move the resident and would call 911. She also said if there was "a lot of blood around the head" she would not move the resident and would call emergency services immediately.
Her reasoning: the resident could have a spinal injury.
The facility's Administrator agreed with this approach when questioned on October 23. She told inspectors she would not want a resident moved if they were found bleeding from the head, had decreased sensations in extremities, or showed changes in extremity range of motion.
But the Director of Nursing gave different guidance. She told inspectors that if a resident is found face-down, she expected staff to conduct an assessment first. However, when discussing the specific incident with Resident #1, she acknowledged that blood was present on the floor and said she would have sent the resident to the emergency room immediately.
The Director of Nursing told inspectors she was "glad that they did not move Resident #1." During her investigation of the incident, she said she found no concerns with the decision to transfer the resident to the emergency room right away.
Staff involved in the actual incident told the Director of Nursing they could not move the resident because of her position. They assumed the blood was coming from the resident's nose.
The Director of Nursing later acknowledged to inspectors that if a resident is found face-down with blood present, they should not be moved and should be sent directly to the emergency room.
The facility's own policy, dated 2021 and revised in March 2018, provides clear direction for these situations. The policy states that if a resident has just fallen or is found on the floor without a witness, staff should evaluate for possible injuries to the head, neck, spine and extremities. Staff should obtain and record vital signs as soon as it is safe to do so.
Most importantly, the policy directs that if there is evidence of injury, staff should provide appropriate first aid and obtain medical treatment immediately.
The inspection revealed a disconnect between written policy and staff understanding. While the facility had established procedures for fall response, key personnel gave conflicting information about when to move residents and when to call for emergency help.
The Assistant Director of Nursing's approach of checking range of motion first could potentially delay emergency care in situations where immediate medical attention is needed. Her statement that she would only avoid moving a resident if there was "a lot of blood around the head" suggests uncertainty about what constitutes a serious head injury requiring emergency protocols.
The Administrator's criteria for not moving a resident included more comprehensive warning signs, including decreased sensations and range of motion changes. But even this approach assumes staff would conduct assessments before determining whether to call 911.
Meanwhile, the Director of Nursing's position evolved during questioning. Initially, she emphasized the need for assessment, but when confronted with the specific circumstances of Resident #1's case, she acknowledged that immediate emergency room transfer was appropriate.
The incident with Resident #1 became a case study in the confusion. Staff found the resident face-down with blood on the floor but made assumptions about the source of bleeding. The Director of Nursing praised their decision not to move the resident, yet also said she would have immediately sent the resident for emergency care.
This regulatory violation falls under federal requirements for accident prevention and falls management. Nursing homes must ensure staff understand and consistently follow established protocols for resident safety, particularly in emergency situations where delayed or inappropriate responses could worsen injuries.
The inspection found that despite having a written policy addressing fall response, the facility failed to ensure staff had consistent understanding of when and how to implement emergency procedures for residents found injured on the floor.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Denison Care Center from 2025-10-23 including all violations, facility responses, and corrective action plans.