The resident hit her head during the fall and was found bleeding on the floor at Aviata at Englewood. She spent several days in the hospital with a non-surgical subdural hematoma before returning to the facility.
Staff A, a certified nursing assistant, was performing incontinence care when he stepped away from the bedside to dispose of a soiled brief and wash his hands, according to the facility's Director of Nursing. The resident required assistance from one to two staff members for turning and repositioning, but the nursing assistant left her in an unsafe position on the bed's edge.
"Staff are supposed to ensure residents are in safe position prior to leaving bedside," the Director of Nursing told inspectors. "The resident was not left in a safe position and this is when Resident #1 fell out of bed."
The nursing assistant told investigators he didn't know the resident very well and wasn't aware she required staff assistance with turning and repositioning. He admitted he hadn't been trained to look up specific information about residents in the Kardex, the computer program accessible to nursing assistants for patient information.
An Advanced Practice Nurse Practitioner who responded to the incident said he wasn't present when the resident fell but was immediately summoned by the nurse on duty. When he arrived, the resident was lying on her back and bleeding from her head.
"The resident was on blood thinners, so they transferred her out immediately to a higher level of care," the nurse practitioner said.
The resident's blood thinner medication made the fall particularly dangerous, increasing her risk of serious bleeding complications. Federal inspectors classified the incident as causing actual harm to the resident.
The Director of Nursing could not verify that Staff A had received training for the Kardex system prior to the resident's fall. She acknowledged conducting the training only after the incident occurred.
The facility Administrator was aware the resident had been injured during care but maintained that the staff member had followed the resident's care plan. However, inspectors found the nursing assistant's actions violated federal requirements for ensuring resident safety during care.
The inspection revealed systematic failures in staff training and supervision. The nursing assistant's lack of knowledge about the resident's specific care needs and his unfamiliarity with basic information systems highlighted gaps in the facility's preparation of direct care staff.
Federal regulations require nursing homes to ensure all staff members can safely perform their assigned duties and have access to essential resident information. Staff must be trained to maintain resident safety at all times, particularly when providing hands-on care to vulnerable individuals.
The incident occurred during routine incontinence care, one of the most basic and frequent nursing tasks in long-term care facilities. The nursing assistant's decision to leave a resident requiring positioning assistance alone on the edge of a bed demonstrated a fundamental failure in safety protocols.
The resident's hospitalization and diagnosis of subdural hematoma represented serious consequences that could have been prevented with proper positioning and supervision. Brain bleeds in elderly residents on blood thinners can be life-threatening and often result in permanent complications.
The facility's response to provide training only after a serious injury occurred suggests reactive rather than proactive safety measures. The Director of Nursing's inability to confirm prior training completion indicates inadequate documentation and oversight of staff competency.
The Administrator's assertion that staff followed the care plan contradicted the Director of Nursing's finding that the resident was left in an unsafe position. This disconnect between leadership perspectives raised additional concerns about incident analysis and accountability.
The resident returned to the facility after several days of hospital treatment, but the lasting impact of her brain injury remains unclear from the inspection records.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aviata At Englewood from 2025-11-24 including all violations, facility responses, and corrective action plans.