The September 18 incident occurred while EMTs waited outside the room to transport the resident for a weekly medical procedure. They heard the resident yell "I am going to fall," followed by a loud thump, according to the EMS report reviewed by inspectors.
The resident, identified as R701 in inspection documents, had been admitted to the facility for end-stage liver disease with ascites — fluid accumulation in the abdomen that required weekly drainage procedures. Despite having no cognitive impairment, the resident's care plan specifically required two-person assistance for bedpan use due to limited mobility and the enlarged abdomen from fluid retention.
Only one certified nursing assistant provided care during the incident.
The EMS crew had arrived to transport the resident to the hospital for interventional radiology when they discovered the resident was using a bedpan. "THE CREW WAITED OUTSIDE OF THE ROOM FOR THE AIDE TO COMPLETE THE REMOVAL OF THE BEDPAN AND CLEAN UP OF THE PATIENT," the emergency medical service report documented.
"THE CREW HEARD A LOUD SOUND RESEMBLING A FALL IN THE ROOM AND ENTERED, AND FOUND THE AIDE IN THE BATHROOM, THE PATIENT WAS APPROXIMATELY 10 FEET AWAY, LAYING ON HER LEFT SIDE ON THE FLOOR."
The resident had knocked over flowers and a lamp during the fall and complained of pain to the left arm. Hospital radiology confirmed a fracture to the left clavicle that same morning.
A physician's progress note the following day documented that the resident "is in some pain associated with the collarbone fracture."
During interviews with federal inspectors on November 12, facility administrators confirmed the safety violation. The Assistant Director of Nursing explained that the resident "was care planned for two persons assist so they would have support to their enlarged abdomen due to ascites, not to roll off the alternating air mattress."
The nurse assigned to the resident's care that day confirmed they were not in the room during the incident and that only one nursing assistant provided care, violating the established care plan.
Facility administrators terminated the nursing assistant responsible for the incident. The termination statement reviewed by inspectors documented that the assistant "failed to follow care orders, follow the care plan designed to maintain R701's safety which resulted in a fall with injury."
The resident's care plan, dated August 23, had clearly documented the need for extensive assistance with two people for bedpan use due to self-care deficits and limited mobility. The resident had scored 15 out of 15 on cognitive testing, indicating full mental capacity to understand their physical limitations.
Federal inspectors cited the facility for failing to ensure the nursing home area was free from accident hazards and for inadequate supervision to prevent accidents. The violation resulted in actual harm to the resident.
The incident highlights the critical importance of following individualized care plans designed to protect vulnerable residents. The resident's enlarged abdomen from liver disease made them particularly susceptible to falls during transfers, which the care plan had specifically addressed through the two-person assist requirement.
The facility's failure to implement this basic safety measure resulted in preventable injury to a resident already dealing with end-stage liver disease requiring weekly medical procedures to drain abdominal fluid.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Caretel Inns of Brighton from 2025-11-12 including all violations, facility responses, and corrective action plans.