Federal inspectors found that Bruceville Terrace failed to notify the responsible party when the resident lost his balance while returning to bed at 1 a.m. on November 23. A certified nursing assistant helped him sit on the floor after the fall.
The resident complained of pain around his lower back and tailbone area. Less than 11 hours later, at 11:50 a.m., he was discharged home with his responsible party.
Nursing notes from the discharge showed no indication that staff informed the family member about the fall that had occurred.
The resident had been admitted with type 2 diabetes and end-stage renal disease. Diabetes creates difficulty controlling blood sugar and poor wound healing. End-stage renal disease means irreversible kidney failure.
When inspectors interviewed the Director of Nursing on December 19, she confirmed that no follow-up call was made to notify the responsible party about the fall. The nursing notes from 2:51 a.m. on November 23 indicated that the morning nurse should follow up, which the Director of Nursing said included calling the responsible party.
No documentation existed showing any follow-up call occurred.
The Director of Nursing told inspectors she expected the day shift nurse to follow up and ensure the responsible party knew about the fall. She also said the nurse should have informed the family member about the fall when they arrived to pick up the resident for discharge.
Neither happened.
The facility's own policy on falling incidents, dated May 22, 2025, requires staff to notify both the physician and responsible party when falls occur.
The inspection found that this failure to communicate left the responsible party unaware of the resident's fall and actual condition. This could impact their ability to ensure appropriate care and support after the resident returned home.
Inspectors classified this as a violation affecting few residents with minimal harm or potential for actual harm. The complaint inspection occurred on December 19, nearly a month after the incident.
The resident's medical conditions made the communication failure particularly significant. Diabetes affects healing and can complicate recovery from injuries. End-stage renal disease indicates the resident's overall fragile health status.
When someone with these conditions falls and complains of pain in the tailbone area, family members need that information to monitor for complications and seek appropriate medical follow-up at home.
The nursing assistant who helped the resident sit on the floor after losing his balance documented the incident. The resident's complaint of sacrum-coccyx pain was also recorded in nursing notes.
But the chain of communication broke down between the overnight staff who witnessed and documented the fall and the day shift responsible for discharge planning and family notification.
The Director of Nursing acknowledged during the inspection that the facility had a clear expectation that the responsible party should have been informed. She pointed to two missed opportunities: the follow-up call that never happened and the face-to-face conversation during discharge pickup that never occurred.
The facility policy leaves no ambiguity about notification requirements when residents fall. The May 2025 policy explicitly states that both the physician and responsible party must be notified of falling incidents.
Inspectors found that one of three residents they sampled had experienced this communication failure, suggesting the problem may not be isolated to this single case.
The responsible party picked up the resident for discharge without knowing about the fall, the complaint of tailbone pain, or the need to monitor for potential complications related to the incident.
This information gap meant the family member was unprepared to provide appropriate observation and care during the critical transition from facility to home. They had no knowledge that the resident had experienced pain in an area vulnerable to serious injury from falls.
For a resident with diabetes and kidney failure, any fall represents a significant event requiring careful monitoring. The failure to communicate this information to the person responsible for the resident's care after discharge created an unnecessary risk during a vulnerable transition period.
The inspection report shows how communication breakdowns can leave families uninformed about critical health events affecting their loved ones, even when facility policies clearly require such notification.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bruceville Terrace - D/p Snf of Methodist Hospital from 2025-12-19 including all violations, facility responses, and corrective action plans.
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