The incident occurred on July 12, 2025, at Seneca Health Care Center. Certified Nurse Aide #1 left Resident #1 unattended on the toilet, violating the resident's individualized care plan that specifically required they not be left alone in the bathroom.
When the resident fell, their left lower extremity became shorter than the right and they experienced pain with passive range of motion. Nurse Practitioner #1 ordered x-rays of the left hip, femur, and pelvis and spoke with the resident's health care proxy about possible surgical intervention.
"Resident #1 being left alone on the toilet was a break in their care plan that resulted in a fracture, which was a serious injury, and the serious injury caused harm to Resident #1," Nurse Practitioner #1 told inspectors during a telephone interview on October 29.
The Medical Director said during an interview that same day that they would have expected Certified Nurse Aide #1 to review Resident #1's care plan before providing care. They stated a fracture was a serious injury and noted there was a possibility the aide could have prevented the fall if they had not left the room.
Federal inspectors found that instead of staying with the resident as required, Certified Nurse Aide #1 should have pulled the emergency call cord in the bathroom and waited for someone to answer it and get them linen.
The Director of Nursing explained during an October 29 interview that a break in a plan of care occurs when staff does not follow the care plan. Their expectation was for all staff to read and follow residents' individualized care plans.
"Ultimately, Resident #1 had an intervention not to be left alone in the bathroom. Certified Nurse Aide #1 left them alone in the bathroom, the resident fell which resulted in a fracture," the Director of Nursing said.
The Director of Quality and Education stated they expected all certified nurse aides to review care plans prior to providing resident care. With the July 12 incident, Certified Nurse Aide #1 did not follow the care plan for Resident #1, and the resident sustained a fracture.
During a re-interview on November 5, the Director of Quality and Education said that after the fall they had determined this was an isolated incident based on trending of falls within the facility. Certified Nurse Aide #1 was re-educated on reading and following the plan of care.
The Administrator told inspectors on October 29 that they expected certified nurse aides to review resident care plans prior to providing care. Not following a resident's plan of care may be a break in their plan, the Administrator said, adding that a broken bone would be a serious injury.
"It was an accident, not intentional," the Administrator stated.
The violation resulted in actual harm to few residents, according to the inspection report. The incident represents a failure to provide care and services to ensure that residents maintained their highest practicable physical well-being and received necessary care to prevent avoidable decline.
The case highlights the critical importance of following individualized care plans, particularly for residents who require constant supervision during personal care activities. The resident's care plan existed specifically to prevent the type of incident that occurred when the aide left them unattended.
All facility leadership interviewed by inspectors acknowledged that the aide's failure to follow the care plan directly contributed to the resident's injury. The fracture required medical intervention and caused the resident to experience pain and physical complications that could have been prevented with proper supervision.
The facility classified the incident as isolated after reviewing fall trends, but the severity of the outcome underscores the potential consequences when staff fail to adhere to established safety protocols designed to protect vulnerable residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Seneca Health Care Center from 2025-11-05 including all violations, facility responses, and corrective action plans.