The incident at Imboden Creek Senior Living began at 5:10 AM on October 18 when staff found a resident on the floor of her room. The night shift assessed her, found no obvious injuries, and helped her back to bed. The licensed practical nurse on duty examined her and documented no findings.
Nobody mentioned the fall to the day shift.
At 7:14 AM, when staff tried to dress the resident for the day, they discovered significant swelling from her right hip to her knee. Her right knee was swollen, she complained of pain when her leg was moved, and touching the area caused additional pain.
The day nurse, interviewed by inspectors, said she had no idea the resident had fallen. The night nurse had left early and passed along shift information on a piece of paper rather than giving a verbal report. The fall wasn't mentioned in the written notes.
"I had no idea that R9 had fallen earlier that morning," the day nurse told inspectors. She said a nursing assistant informed her around 7:15 AM that the resident's right leg was swollen and she was complaining of pain.
The day nurse found the resident's right knee was pinker and more swollen than her left knee, though she saw no bruising or obvious deformity. She gave the resident acetaminophen for pain and applied an ice pack to reduce swelling. She contacted the physician and tried to figure out what had happened to cause the knee problem.
The resident wasn't sent to the emergency room until 5:53 PM that evening.
X-rays revealed an acute, displaced fracture of the distal femoral shaft — a severe break in the thighbone near the knee. The radiologist's report documented an acute oblique fracture of the distal femoral diaphysis.
The night nurse who witnessed the original fall and failed to report it could not be reached for comment. Inspectors left a voicemail on November 4 requesting an interview, but received no response.
The director of nurses confirmed the communication breakdown. She told inspectors the night nurse "did not report R9's unwitnessed fall to the next shift, nursing management, V19 Physician nor V40 (R9's) Power of Attorney." She acknowledged the fall "should have been reported to all of the necessary people and was not."
Federal regulations require nursing homes to immediately notify residents' doctors and family members of situations that affect the resident, including injuries and changes in condition. The failure to communicate about the fall meant the resident's fractured femur went unrecognized for hours while she experienced pain and swelling.
The day nurse's account reveals the cascade of problems that resulted from the missed communication. She administered basic comfort measures — pain medication and ice — for what appeared to be unexplained knee swelling, unaware that the resident had suffered a traumatic fall that could have caused serious injury.
The resident endured more than 12 additional hours of pain before receiving emergency medical care. During that time, the displaced fracture remained untreated, potentially complicating her recovery and rehabilitation.
The inspection, conducted November 6 following a complaint, found this communication failure affected one of four residents reviewed for falls. Inspectors examined records for eleven residents total as part of their sample.
The facility's violation was classified as causing minimal harm or potential for actual harm, affecting few residents. However, the specific resident involved suffered a serious fracture that required emergency treatment and likely surgical intervention.
The case illustrates how communication breakdowns between nursing shifts can have severe consequences for residents' health and safety. When the night nurse left early and failed to provide proper verbal report about a significant incident, the day shift had no way to monitor the resident appropriately or recognize developing complications.
The resident's family, listed as her power of attorney, was never notified of the fall or the developing complications until the emergency room visit nearly 13 hours later.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Imboden Creek Senior Living from 2025-11-06 including all violations, facility responses, and corrective action plans.