The incident occurred on October 24, 2025, at Vancrest of Ada, where Resident #50 was discovered with what nursing staff described as a "pressure ring" on both sides of her buttocks after being left on a bedpan.
Resident #32, the injured woman's roommate, told federal inspectors she witnessed a certified nursing assistant retrieve the bedpan from a bathroom bag during the early morning hours of October 24. The bedpan was typically stored in the bathroom when not in use.
Later that morning, LPN #310 received a report during shift change that Resident #50 "had been left on the bedpan and had a pressure ring." Despite this knowledge, the licensed practical nurse confirmed to inspectors she did not monitor or assess the wound during her shift.
The resident's condition deteriorated throughout the day. LPN #310 contacted a physician and received orders to send Resident #50 to the emergency department for evaluation and treatment. When calling the hospital to provide report before the resident's arrival, LPN #341 informed hospital staff about "the resident's wounds on her bottom from being left on the bedpan."
Medical providers working in the facility that day remained unaware of the injury for hours. Nurse Practitioner #415 had examined Resident #50 on October 24 for an acute illness after the resident's roommate reported she "had been talking out of her mind." During that visit, NP #415 found the resident was "arousable and was able to answer questions, but she was not her usual self."
The nurse practitioner told inspectors that normally she and Resident #50 would "banter back and forth," but this interaction didn't occur during the October 24 visit. She ordered testing and treatment for a suspected urinary tract infection.
Crucially, NP #415 confirmed she was still in the facility when the pressure ulcer was discovered but was never notified about the skin injury. She only learned about it during the federal inspection interview weeks later.
Another nurse practitioner, NP #420, also told inspectors she was not notified of Resident #50's wound and first learned about it during the inspection interview. When shown photographs from the hospital, NP #420 identified the injury as a deep tissue injury, a type of pressure ulcer caused by pressure from an object.
The failure to communicate about the injury violated the facility's own policies. Vancrest of Ada's pressure ulcer policy, revised in October 2016, required staff to assess all residents regularly to determine the presence of skin conditions and identify potential risk factors. The policy specifically stated that floor nurses were responsible for obtaining measurements of wounds, updating physicians, and applying appropriate treatments.
The facility's wound care policy mandated following state and federal regulations to prevent and heal pressure ulcers, ensuring residents would not develop avoidable wounds while in their care and would receive appropriate treatment for existing wounds.
Federal inspectors determined the incident caused actual harm to the resident and represented a violation of care standards. The inspection was conducted in response to a complaint filed with regulators.
Pressure ulcers from medical equipment like bedpans are considered largely preventable with proper monitoring and positioning. The injuries can cause significant pain and lead to serious infections if not promptly treated.
The case highlights communication breakdowns that can occur in nursing homes when multiple staff members care for the same resident across different shifts. Despite having medical providers in the building treating Resident #50 for other conditions, the facility's nursing staff failed to alert them to the new injury requiring immediate attention.
Resident #50's roommate served as a key witness to both the bedpan incident and her declining mental status that prompted the medical evaluation. The roommate's observations ultimately helped piece together the timeline of events that led to the preventable injury.
The inspection found that facility policies existed to prevent such incidents but were not followed by staff members responsible for the resident's care that day.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Vancrest of Ada from 2025-11-06 including all violations, facility responses, and corrective action plans.