The October 18 incident occurred when the resident, who normally used a walker, attempted to use the bathroom independently. Call light records show the emergency bathroom light activated at 9:20 AM but wasn't answered until 9:57 AM.
During those 36 minutes, the resident lay on the bathroom floor with a head wound.
The resident had pulled the emergency cord in the bathroom at 9:20 AM. Nineteen minutes later, at 9:39 AM, someone activated the regular nurse call light from the resident's room. That call was answered eight minutes later, at 9:47 AM. But the emergency bathroom light continued flashing until 9:57 AM.
When staff finally responded, they found the resident on the floor, leaning against a recliner, bleeding from the left side of the head.
CNA #1, who discovered the resident, told inspectors she was unfamiliar with this resident and had been told the person was "fairly independent." She found the resident after noticing the call light was on, then immediately notified the nurse and another CNA.
The resident told the responding nurse about being on the floor "for a while" and admitted to attempting the bathroom trip without using the required walker. The nurse found the resident alert and at cognitive baseline with normal vital signs, but recommended hospital evaluation because the resident was taking Plavix, a blood-thinning medication that increases bleeding risks.
The facility administrator revealed a critical system flaw to inspectors: emergency bathroom lights and regular nurse call lights produced identical tones, making it impossible for staff to distinguish between routine requests and true emergencies.
Staff had documented rounding on the resident at 9:00 AM, twenty minutes before the emergency call. The resident typically didn't use call lights, and no alarms were heard during the incident.
RN #1 told inspectors that when she entered the cottage that morning, the CNA reported the fall. She observed the hematoma on the resident's head and assisted with a bathroom request. During that interaction, the resident acknowledged the previous bathroom attempt without the walker.
The nursing supervisor interviewed by inspectors said the facility "probably could use more staff," though she didn't specify current staffing levels or cite specific shortages.
Federal inspectors determined the delayed response caused actual harm to few residents. The facility received a citation under federal regulation F 0689, which requires nursing homes to provide necessary care and services to promote or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.
Green House Living implemented several changes following the incident. Staff received training on November 12. The facility reprogrammed the call light system that same day so emergency bathroom calls now produce different tones than regular nurse calls. Managers also introduced a handoff tool for staff communication and began conducting call light response time audits.
The resident was transferred to the hospital on October 18 for evaluation and treatment of the head injury.
The inspection occurred November 19 following a complaint about the incident. Federal records show the facility administrator acknowledged that call lights should be answered immediately and confirmed the facility developed an improvement plan after the fall.
The case highlights how equipment failures can compound staffing challenges in nursing homes. When emergency calls sound identical to routine requests, staff cannot prioritize responses appropriately. For a resident taking blood-thinning medication, every minute on the floor with a head injury increases the risk of serious complications.
The 36-minute delay between the emergency call and response represents more than half an hour of potential bleeding and trauma for someone whose medication made such injuries particularly dangerous.
Full Inspection Report
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