A small nursing home in Buhl has been cited for neglect in the case of a resident who fell on a concrete sidewalk just outside the facility and later died as a result of her injuries.

In a report published online on Tuesday, the state's Office of Health Facilities Complaints found that "based on a preponderance of evidence, neglect occurred" in the incident last May 5 at Cornerstone Villa, a locally owned, not-for-profit, 44-bed nursing home.

Newsletter signup for email alerts

The Office of Health Facilities Complaints, which is part of the state Department of Health, found that the facility made needed corrections and was back in compliance with state standards as of last September.

But Debra Doughty, the nursing home's administrator, said she and her staff acted immediately after the incident occurred to correct the problem.

"We were back in compliance right after it happened," Doughty said in a telephone interview.

According to the online report concluded on Dec. 21 by investigator Carol Bode, the resident had been admitted to Cornerstone Villa one day before the incident, with "Alzheimer's, sensory difficulty and generalized weakness."

The woman knew who she was, Bode learned, but had no concept of time or place. A physical therapist evaluated her on the morning of May 5 and determined that a staff member should have a hand on the resident whenever she walked to prevent falls.

But later that evening, five staff members saw the resident walking with the aid of a walker but did not intervene, Bode reported. When an alarm sounded indicating the front door had opened, a nursing assistant and a licensed practical nurse found her "lying face down on the sidewalk, moaning with a lot of blood present."

According to the facility's own investigative report, it appeared the woman's walker had gotten tangled in the door frame, Bode reported.

The resident was taken to a local hospital with "multiple facial fractures," and then was transferred to a larger hospital, according to the report. Because of the severity of her injuries, family members opted for "comfort care," and the woman died in the hospital two days later.

The death certificate indicated the cause of death was "complications of cranial facial fractures secondary to a fall."

Doughty said the failure "was just one where, with a new person, it was like the right hand didn't know what the left hand was doing. It was obvious to us given the incident that there was a problem. We corrected it internally before there was a state investigation."

She was confident the steps had been taken to prevent a similar incident from happening again, Doughty said.