The injuries to Resident #1 went undetected for hours at Liberty Commons Nursing & Rehab Center of Southport until a hospice aide arrived on October 2nd to give the woman her bath and discovered dark purple bruising across her right forehead and blue-red bruising around her right eye.
The hospice aide also found slight redness on the left side of the resident's neck, bruising on her right shoulder and right knee, and redness and bruising on her left knee and foot. The woman's left leg was pulled up and she refused to let nurses touch it. X-rays later revealed a tibia fibula fracture.
But a nurse aide had already reported unexplained marks and bruising on the resident to the night shift nurse at 5:00 AM that morning. Nurse #5 never went to check on the patient.
"Nurse #5 should have gone to the room and checked Resident #1 and completed a full assessment at 5:00 AM on 10/2/25 when Nurse Aide #3 reported unexplained marks and bruising but Nurse #5 did not do that," the Director of Nursing told state inspectors.
The day shift nurse, identified as Nurse #1, said the night nurse "did not report anything at all" about the resident during shift change that morning. When Nurse #1 arrived at 7:00 AM, she had no knowledge of the aide's earlier report.
It wasn't until before 8:00 AM, when the hospice aide was already in the room and another nurse aide asked Nurse #1 to examine the patient, that anyone in authority assessed the extensive injuries.
Nurse #1 found the resident had been at baseline with no bruising the previous day on October 1st, and no falls or injuries had been reported during her shift. The woman was oriented only to person and engaged in nonsensical conversation, which staff said was normal for her.
The resident appeared comfortable and rated her pain level at zero during the inspection visit. Staff administered morphine concentrate as needed with good effect.
But the facility's response revealed multiple protocol failures beyond the night nurse's inaction.
When Nurse #1 discovered the unexplained facial bruising around 7:30 AM, she should have initiated neurological assessments every hour for four hours, then every shift for a total of 48 hours, according to the Director of Nursing. She didn't.
The Assistant Director of Nursing compounded the problem when she recorded one of the neurological assessments later that day. The electronic medical record automatically pulled the most recent vital signs, which were from September 30th, two days old.
"She stated that was done in error on her part and she should have ensured up to date vital signs were done and recorded in the medical record," inspectors noted.
Nurse #1, who worked for an agency, told investigators she wasn't certain what the facility's protocol was for checking neurological assessments following unwitnessed injuries. The neurological assessments she completed were only what appeared in the electronic medical record.
The facility launched a full investigation at 8:00 AM on October 2nd after the hospice aide's discovery, according to the Director of Nursing. The resident was evaluated at a hospital and diagnosed with facial bruising and the leg fracture.
Staff told inspectors they presumed the injuries resulted from a fall, though no fall had been witnessed or reported. The facility ordered mobile X-rays and notified appropriate agencies about the injuries.
The resident had terminal multiple myeloma and was receiving hospice care. During the inspection visit, she rested quietly in bed with her eyes closed but aroused to voice and touch. She smiled at inspectors and was able to move her right leg, but kept her injured left leg pulled up and refused to allow examination.
The case illustrates how communication breakdowns during shift changes can leave vulnerable residents without proper medical attention for hours. The night nurse's failure to investigate the aide's 5:00 AM report meant the injured woman went without assessment or pain management until the hospice aide's arrival three hours later.
State inspectors classified the violation as causing minimal harm or potential for actual harm to few residents. But for Resident #1, already facing a terminal diagnosis, the delayed response to her unexplained injuries represented another layer of suffering in her final days.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Liberty Commons Nursing & Rehab Center of Southpor from 2025-11-19 including all violations, facility responses, and corrective action plans.
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