**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of select facility policies, review of facility documentation, and staff interview, it was determined that the facility failed to prevent resident neglect that resulted in a fall and serious injury for one of seven residents who sustained a fall resulting in a fractured left femur.

Review of the information dated (MONTH) 12, (YEAR), submitted by the facility reflected that on (MONTH) 11, (YEAR), at 5 a.m. the resident was in bed and Employee 1, a Nurse Aide, had been providing incontinence care. The information reflected that Employee 1 had rolled the resident away from herself (away from Employee 1). The information indicated that the resident had fallen from bed to the floor. The resident was transferred to the hospital where she was found to have a fractured left femur (thigh bone). Facility documentation reflected that the resident underwent [REDACTED]. Facility documentation reflected that in an interview on (MONTH) 13, (YEAR), Employee 1 admitted that the resident fell off the bed when she (Employee 1) had rolled the resident away from herself. In this interview, Employee 1 also admitted that she had been providing care alone when the resident fell off the bed. In a report initially submitted to the Department on (MONTH) 15, (YEAR), the facility alleged that Resident CR1′ s fall was the result of neglect by Employee 1. The facility documented that Employee 1 did not follow, proper protocol for bed positioning and did not ask for help with the resident. The facility documented that the allegation of neglect, was substantiated and (Employee 1) was at fault.

In an interview on (MONTH) 16, (YEAR), at 2:25 p.m. the Director of Nursing stated that Employee 1 failed to roll the resident towards her while providing incontinence care and bed linen change, that resulted in a fall with injury on (MONTH) 11, (YEAR).

Personal Note from NHA-Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect. You can make a difference. If you have a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately. We have helped many already and we can help you and your loved one as well by filing a state complaint, hiring a specialized nursing home attorney or helping you find a more suitable location for your loved one. Contact us through our CONTACT FORM located on our website here below or on the sidebar or call our toll free hot line number: 1-800-645-5262. You can make a difference even if your loved one has already passed away.