The incident at Concordia at Villa St Joseph violated the facility's own policy requiring licensed nurse assessment before moving any resident after a fall. State inspectors documented the violation during a December 30 complaint investigation.
The resident described the November 15 fall during an interview with inspectors on December 20: "I was getting ready for bed, I used a walker, I stood up grabbed my walker went to pivot and I just kind of slumped down, the aid was by me, I went down slow not hard, just slowly on my left side she made sure I was alright and went and got another aide they used the lift to get me back in bed."
The resident has diabetes, heart failure, and obstructive uropathy, which restricts urine flow, according to his September assessment.
Facility policy on incidents and accidents, last reviewed January 2, states that injuries will be assessed by a licensed nurse or practitioner and affected individuals will not be moved until safe to do so.
The nursing aides ignored this requirement.
According to facility investigative reports and nursing notes reviewed by inspectors, the two nursing assistants returned the resident to bed using a mechanical lift but failed to notify any registered nurse or practitioner for an injury assessment before moving him.
This wasn't an isolated training issue. Employee counseling reports from November 17 show the facility had already re-educated two nurse aids that residents who fall require evaluation from a registered nurse before being assisted into bed or chair.
The certified nursing assistant job description requires aides to communicate observations and findings to the charge nurse. That didn't happen either.
During the December 30 inspection, the Director of Nursing confirmed the facility failed to provide appropriate treatment and care by not assessing the resident after his fall.
The resident's slow, controlled fall might have seemed minor to the aides present. He went down gradually on his left side rather than hitting the ground hard. The aide who witnessed it made sure he was alright before getting help.
But the facility's policy exists for a reason. Falls can cause internal injuries, fractures, or other complications that aren't immediately visible, particularly in elderly residents with multiple medical conditions like diabetes and heart failure.
The nursing aides' decision to use a mechanical lift suggests they recognized the resident couldn't get up on his own power. Yet they proceeded without the licensed nurse evaluation that facility policy required before any movement.
State regulations mandate that nursing homes provide appropriate treatment and care according to orders and resident preferences. The facility violated this standard by failing to follow its own safety protocols.
The inspection found this was one of four residents affected by care deficiencies, though details on the other three cases weren't provided in the available documentation.
The resident who fell has remained at the facility since his admission earlier this year. His September assessment showed he needed assistance with daily activities due to his multiple medical conditions.
Two months after the November re-education of nursing aides about fall protocols, the same violation occurred. The aides who moved the resident knew or should have known the policy requiring RN assessment before repositioning any fall victim.
The Director of Nursing's confirmation during the inspection that the facility failed to provide appropriate care suggests management recognized the seriousness of the protocol violation.
The resident's description of his fall reveals he was using his walker properly and attempting a routine pivot when he lost stability. His controlled descent and the aide's immediate presence indicate this wasn't a case of neglect or abandonment.
Instead, it represents a fundamental breakdown in following established safety procedures designed to protect vulnerable residents from further harm after accidents.
The facility now faces state oversight to correct its fall response protocols and ensure nursing staff understand when licensed nurse evaluation is mandatory, not optional.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Concordia At Villa St Joseph from 2025-12-30 including all violations, facility responses, and corrective action plans.