**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review and staff interview, it was determined that the facility failed to provide the necessary interventions to ensure residents were free of accident hazards resulting in a fall, laceration to the forehead, transfer to the hospital and sutures for one of three residents reviewed (Resident 1).

Review of facility investigation documentation regarding a fall that Resident 1 experienced on (MONTH) 5, (YEAR), at approximately 11:00 p.m. revealed that Nursing Assistant (NA) 2 was providing incontinence care to Resident 1 without the required second staff person. NA 2 rolled the resident away from her and the resident rolled out of the bed onto the floor. Resident 1 sustained a laceration to the frontal area of the head that required sutures.

During an interview with the Nursing Home Administrator on (MONTH) 7, (YEAR), at approximately 2:30 p.m. she revealed that NA 2 did not follow Resident 1’s plan of care and should have had the 2nd staff person to perform the ADL care.

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.