Resident 2 had been admitted to Cedarwood Rehabilitation & Healthcare Center on April 4, just days after hip fracture surgery from a fall at home. Her care plan, initiated the same day, specified that two staff members were required for bed mobility due to her condition and confusion.
Three days later, Nurse Aide 1 was alone with the resident when he decided to change her bedding. According to his written statement, he rolled the patient to her side while she held onto the nightstand. She fell to the floor anyway.
X-ray reports from April 7 revealed the extent of her injuries: a nasal bone fracture, an acute fracture through the base of the odontoid process in her neck, and a left frontal scalp laceration requiring sutures. The odontoid process is a bony projection of the second cervical vertebra that helps stabilize head movement.
Nurse Aide 1 admitted in his written statement that he never reviewed the resident's Kardex documentation system before providing care. The Kardex contains key patient information from care plans, including mobility requirements. He stated he didn't know she required two staff members for bed movement.
The aide had received training on reviewing resident Kardex information just two months earlier, signing education records on February 14. Despite this training, he proceeded to move the patient alone.
The Director of Nursing confirmed during an April 17 interview that Nurse Aide 1's failure to follow the care plan directly resulted in the resident's fall and subsequent facial and neck fractures.
The facility immediately transferred the resident to the hospital following the incident. Nurse Aide 1 was removed from patient care, interviewed, and suspended that same day. He was terminated after admitting he failed to follow the resident's care plan for bed mobility.
State inspectors interviewed alert residents to determine if they received care according to their plans. They also observed and assessed non-interviewable residents for injuries resulting from improper mobility assistance.
The facility conducted facility-wide re-education on April 8 and 9, requiring all nursing staff to receive training on reviewing resident Kardex and care plans before providing care. Education records documented completion by all nursing personnel.
As part of corrective measures, the Director of Nursing implemented an audit system to monitor care plan compliance. The audits would review five random residents' care five days a week for one week, then three days a week for another week, followed by weekly audits for one month. Additional audits would be determined by the facility's Quality Assurance Performance Improvement committee.
The inspection classified this as actual harm affecting few residents, representing past non-compliance with federal requirements for accident prevention and adequate supervision.
The resident had already endured one traumatic fall at home that required hip surgery. Her admission to the rehabilitation center was meant to provide safe recovery and therapy. Instead, a single aide's decision to ignore established safety protocols resulted in additional fractures to her face and the delicate bones supporting her head and neck.
State inspectors found the facility's response adequate, noting staff compliance with re-education requirements during follow-up interviews. However, the damage to Resident 2 was already done, requiring additional medical treatment and potentially complicating her recovery from the original hip fracture that brought her to the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cedarwood Rehabilitation & Healthcare Center from 2025-04-17 including all violations, facility responses, and corrective action plans.
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