The resident, identified as R5 in inspection records, sustained a silver dollar-sized bruise on her shin and ankle during a transfer on October 21. Physical therapy staff discovered the swelling and bruising around 10:50 that morning and immediately notified the registered nurse.
The woman told staff her feet "gave out" during a transfer. She explained she had broken the same leg three times previously and had hardware from past surgeries.
A nurse practitioner who happened to be in the building quickly assessed the injury. The bruise showed redness and swelling spreading around the impact site. Given the resident's history of multiple fractures in that leg, the nurse practitioner ordered immediate transport to the emergency room for imaging.
Emergency medical services transported the woman to the hospital around 8:45 that morning.
Nobody called her emergency contact.
The resident's emergency contact, identified as V29, learned about the injury and hospitalization when the resident called her from the emergency room. "R5 called her and told her she got her left foot stuck in the wheelchair wheel and her left foot/lower leg was injured and she was sitting in the emergency room," according to inspection records.
V29 told inspectors on October 31 that she was upset about the lack of notification. She said if facility staff had informed her about the severity of the injury, she would have met the resident at the emergency room to provide family support.
The facility's own policy, dated December 2024, explicitly requires notification in these circumstances. The policy states its purpose is "to ensure that the resident's family and/or representative" are contacted about significant changes in a resident's physical status.
The policy specifically lists "onset of swelling, skin discoloration and transfer of the resident from the facility" as conditions requiring family notification.
The procedure section mandates that "when any of the above situations exists, the licensed nurse will contact the resident's representative." It requires staff to keep calling "until they are reached."
The policy even allows for voicemail messages, though it specifies these should not include specifics but should request a callback to the facility.
None of this happened.
The resident's quarterly assessment, completed in recent months, documented that she was alert and capable of understanding her situation. Her face sheet listed V29 as her emergency contact.
Federal regulations require nursing homes to immediately notify residents' doctors, family members, and emergency contacts about injuries, significant changes in condition, or transfers to hospitals. The requirement exists because family members often serve as advocates and sources of support during medical emergencies.
The failure represents a breakdown in basic communication protocols that nursing homes are federally mandated to maintain. When residents suffer injuries serious enough to require emergency room evaluation, their families have the right to know immediately.
In this case, the resident faced the emergency room experience alone while her family remained unaware of her condition. The injury involved a leg with a complex surgical history, making family presence potentially crucial for providing medical history to emergency room physicians.
The woman's emergency contact expressed particular frustration that she could have provided support during what was likely a frightening experience for the resident. Instead, the resident had to navigate the emergency room alone and take responsibility for notifying her own family about the injury and hospitalization.
The inspection found that physical therapy staff, the registered nurse, and the nurse practitioner all responded appropriately to the injury itself. They recognized the severity of the situation given the resident's surgical history and ordered prompt medical evaluation.
But the communication chain broke down completely when it came to family notification. Despite having clear policies and federal requirements, no staff member made the required call to the emergency contact.
The resident spent hours in the emergency room before her family even knew she had been injured. By the time V29 received the call from the resident herself, the opportunity for immediate family support had passed.
Federal inspectors cited the facility for failing to follow notification requirements, finding that the violation affected few residents but represented minimal harm or potential for actual harm. The citation indicates the facility must develop a plan to ensure proper family notification in future emergencies.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hillsboro Rehab & Hcc from 2025-11-04 including all violations, facility responses, and corrective action plans.