Resident U was being transferred with a Hoyer lift on December 8 when the equipment tipped and she hit her forehead on the weight mechanism. A large hematoma appeared immediately on her forehead, according to a nurse's note from that day. Staff gave her pain medication and an ice pack.
Five days later, on December 13, her physician ordered a CT scan of her head and face due to the direct trauma, large frontal hematoma, and bruising around her eyes.
The scan was never done.
When inspectors interviewed Resident U on December 30, she still showed the effects of the lift accident more than three weeks earlier. Faded bruising extended from below her right eyebrow to below her right eye. A dark red and purple quarter-sized bruise remained visible on top of her right cheekbone.
Resident U told inspectors she had been told she was supposed to have a CT scan but hadn't received one.
Her medical record showed she had previously fractured her right femur in a fall and was taking aspirin twice daily as part of antiplatelet therapy. The combination of blood-thinning medication and head trauma made the missing scan particularly concerning.
The Regional Nurse Consultant confirmed to inspectors she couldn't find any CT scan report from December 13 or after. She said she would follow up to see if the scan had been completed.
It hadn't.
The next day, December 31, the Regional Nurse Consultant admitted to inspectors that the CT scan ordered 18 days earlier had never been completed, though it should have been done.
The facility's own policy, provided to inspectors by the Assistant Director of Nursing, required staff to submit timely requests for physician-ordered services including radiology tests. The policy stated the facility would maintain a schedule of diagnostic tests in accordance with physician orders and provide services according to professional standards of quality.
Mechanical lift accidents can cause serious injuries, particularly head trauma that may not be immediately apparent. CT scans help doctors identify brain bleeding, skull fractures, and other internal injuries that could prove fatal if left untreated.
For Resident U, who was already on blood-thinning medication due to her previous fracture, any internal bleeding from the head injury could have been especially dangerous. The aspirin she took twice daily would make it harder for bleeding to stop naturally.
The inspection found the facility failed to ensure physician orders were carried out for treatment and care. Inspectors reviewed three residents and found the problem affected Resident U.
Brickyard Healthcare - Fountainview Care Center operates under a policy that promises reliable processes for providing physician-ordered services consistently. But when a mechanical lift malfunctioned and injured a resident's head, creating visible bruising that lasted for weeks, the facility couldn't manage to complete a single diagnostic test.
Resident U remained in her room with faded bruising around her eye, a quarter-sized bruise on her cheekbone, and no answers about whether the lift accident had caused internal damage to her brain. The CT scan that might have provided those answers sat as an unfulfilled order in her medical chart, 18 days overdue.
The facility's nursing consultant acknowledged what Resident U already knew: the scan should have been done. But for nearly three weeks, nobody had made sure it happened.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brickyard Healthcare - Fountainview Care Center from 2025-12-31 including all violations, facility responses, and corrective action plans.