State Inspections in Nursing Homes Can Reveal Nursing Home Neglect

State Inspections in Nursing Homes Can Reveal Nursing Home Neglect

Federal nursing home safety regulations are enforced at the state level through state departments of health. This is done by “surveys” which are inspections. They happen once per year automatically, but in the event of a complaint by a resident or resident family member, the state will come in and do a “complaint inspection” of the nursing home. In Georgia this is through the Georgia Healthcare Facility Regulation Division. North Carolina nursing homes are regulated by the North Carolina Division of Health Services Regulation. Kentucky has its Division of Healthcare, a division of the Cabinet for Health and Family Services.

In the event of abuse or neglect in a nursing home, residents or their families should make a complaint. In some cases, the state will “substantiate” the complaint, meaning a finding that the nursing home did violate a safety regulation. I’ve had numerous cases over the years where the state did not substantiate a complaint from a victim or client. Depending on the facts of the case, this may ultimately not matter in the decision whether to pursue the case. However, in some cases survey findings can be critical, and extremely important. This is most often true with cases where there is a definite event like a fall with injuries like head injuries with brain injury or intracranial/brain bleeds like subdural hematomas or hemorrhage, or with a broken hip/femur or other broken bones. Most often, the nursing home will not put much detail in the resident’s actual records about what really happened, and to determine the viability of a case, the medical records are the key starting point, and essentially the medical records are all the victim and family (and nursing home abuse lawyer) have to go on. And, some fall cases can be hard to prove without a witness and based on the records only.

But if a survey is done, the surveyor will not only review the records, but they will take into account other things that will never appear in the medical records and which are not available to the attorney or medical experts for review. They will talk to witnesses at the facility to get details about incidents like falls. They will review facility policies relating to the type of incident and injury, such as the nursing home’s fall policy. This can even result in the disclosure of things that no nursing home would ever put in the medical record, such as the failure to use fall prevention interventions like bed alarms. This is an actual survey excerpt in a case where the medical record basically only stated that the resident was found sitting on the edge of the bed after an unwitnessed fall. The survey findings revealed much more:


On 05/07/21 and 05/08/21 a male patient, in his 70s, experienced two unwitnessed overnight falls. He was transferred to an acute care hospital where he was reportedly found to have subdural bleeding (leakage of blood into the membrane between the brain and skull from a torn vessel) consistent with a brain injury.

The facility conducted an internal investigation and notified the physician, coroner, and family/guardian. The patient experienced two unwitnessed overnight falls. The first fall occurred on 05/07/21 at 10:28 p.m. Staff was alerted to the fall when a bed exit alarm sounded. The patient was assessed and no obvious injuries were identified. A physician was notified of the event. The patient then received toileting assistance by a certified nurse aide (CNA) at midnight. The facility reported it was likely that the bed alarm was not set by the CNA after the patient was returned to bed. A registered nurse (RN) was working outside of the patient’s doorway to provide dose oversight, but left to provide blood pressure medication to another assigned patient. When the RN returned around 1:00 a.m,, the patient was seated at the edge of the bed and had a new laceration to his head. The facility concluded the patient fell out of bed, struck his head, and was able to get himself back to the edge of the bed. The RN notified the physician at 1:09 am that the patient had a laceration on his forehead with uncontrolled nose bleeding, and the patient was transferred to the acute hospital via ambulance at 2:04 am. At the acute hospital, the patient was reportedly found to have subdural bleeding consistent with a brain injury. The patient received care in the acute hospital’s intensive care unit. He passed away on 05/13/21.”

As you can see, this nursing home resident died as a result of a head injury (brain bleed) from a fall, and the cause was the failure to ensure the bed alarm, an important fall intervention, was in place. In my experience, the lack of staffing in this nursing home prevented the proper supervision of this resident as well. In order to get to this kind of information without this survey finding, a lawsuit would have to be filed and litigated against the nursing home, and this would have to be done without really knowing whether there was negligence at all. This can be cost and resource prohibitive due to the amount of time and money it costs to pursue cases like nursing home or assisted living cases.

A lawyer who practices nursing home abuse law should know where to direct victims of nursing home negligence or wrongful death in order to get a complaint filed, and clearly this is a very important step that can make a huge difference in the decision whether pursuing a case is feasible. Contact Pleasant Law, PLLC and attorney Thomas Pleasant, an experienced nursing home abuse and wrongful death law firm and lawyer serving Georgia, Kentucky, and North Carolina if you believe you have a nursing home negligence or abuse situation. There is no charge to consider your case and cases are handled on a contingency fee basis (no fees unless there is a recovery).

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