The incident occurred at Kalkaska Memorial Health Center on October 5, when Resident #3 slipped off the edge of his bed at 10:45 PM. Staff found him sitting on the floor next to his bed at 1:21 AM, complaining that his left hip hurt.
The resident was transported to the hospital for X-rays, which revealed displaced fractures of the left superior and inferior pubic rami — breaks in two bones that form the front part of the pelvis.
His daughter wasn't called until 7:05 AM, after the day shift nurse arrived.
"I would have liked to have been there for my father," the daughter told inspectors during a phone interview on October 16. "I believed he must have been confused, and scared. My presence would have calmed him and alleviated any fears."
The resident had been admitted to the facility with diagnoses including dementia and behavioral disturbances. A mental status test in May scored him 5 out of 15, indicating severe cognitive impairment.
Two staff members working that night confirmed the delay to inspectors. Certified Nursing Assistant D said nursing staff were supposed to notify families when there is a change in condition. Licensed Practical Nurse F, who was also working the overnight shift, admitted they did not call the resident's power of attorney.
The facility's own post-fall documentation confirmed the timeline. The form showed the resident fell at 10:45 PM but the section for documenting family notification was filled in with the next morning's time: 7:05 AM on October 5.
No family or power of attorney notifications were documented at the time of the fall itself.
Federal inspectors found the eight-hour delay potentially delayed "decision-making and necessary interventions" for a resident with severe cognitive impairment who had sustained significant injuries.
The nursing home administrator told inspectors the facility does not have a specific policy about notifications for change in condition.
The daughter described her father's likely mental state during those overnight hours alone with his injuries. She believed he would have been confused about what happened to him and frightened by the pain and hospital transport.
The resident had told staff he went to sit up at the edge of his bed and slipped off. With his severe dementia, understanding why he was suddenly in pain and being taken for medical tests would have been particularly difficult without family present.
Hospital X-rays confirmed the seriousness of his injuries. Displaced fractures of the pubic rami typically cause significant pain and mobility limitations, especially problematic for elderly residents with cognitive impairment who may not understand why movement has become difficult.
The inspection report noted that federal regulations require facilities to immediately notify residents, their doctors, and family members of situations that affect the resident, including injuries and changes in condition.
Staff working that night acknowledged they knew the notification requirements but failed to follow them. The certified nursing assistant specifically stated that nursing staff were supposed to notify families when there is a change in condition.
The licensed practical nurse made no excuse for the failure, simply confirming they did not make the required call.
The facility's lack of a specific notification policy emerged as a contributing factor. Without clear written procedures, staff apparently defaulted to waiting for the day shift to handle family communications, even for serious overnight injuries.
The daughter's comments revealed the human cost of the delay. Beyond her desire to comfort her confused father, her presence could have facilitated medical decision-making during the critical hours after his fall.
As his power of attorney for both medical care and financial decisions, she had legal authority to make healthcare choices on his behalf. The eight-hour delay meant those decisions proceeded without input from his designated representative during the initial treatment phase.
The resident remained at the facility following his hospital treatment for the pelvic fractures. His daughter continues to serve as his power of attorney, now aware that overnight emergencies may not prompt immediate notification despite federal requirements.
Federal inspectors classified the violation as causing minimal harm with potential for actual harm, affecting few residents. The finding resulted from a complaint investigation conducted on November 26, 2025.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Kalkaska Memorial Health Center from 2025-11-26 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Kalkaska Memorial Health Center
- Browse all MI nursing home inspections