DALLAS, TX - Federal inspectors issued an immediate jeopardy citation to The Hillcrest of North Dallas after a physical therapy student dropped an elderly resident during a transfer, causing a leg deformity that required emergency hospitalization.
![The Hillcrest of North Dallas exterior]
Unsupervised Student Causes Serious Injury
The incident occurred when an elderly male resident with dementia, osteoporosis, and muscle weakness was being transferred at the facility. According to the inspection report, the resident "was dropped" during the transfer and sustained "a deformity to the R anterior tibia."
The resident, who required a Hoyer lift for safe transfers and typically needed two therapists present during therapy sessions, was immediately sent to Medical City hospital. Hospital documentation noted the patient "presented with RLE pain" and confirmed he "was being transferred at his nursing facility when he was dropped."
An in-house X-ray was performed at the facility, but the resident was transported to the hospital before results were available, indicating the severity of the situation required immediate medical attention.
Medical Implications of the Transfer Accident
The resident's medical history made this incident particularly dangerous. With diagnoses including age-related osteoporosis, osteopenia, muscle weakness, lack of coordination, and dementia, he was extremely vulnerable to injury from improper transfers.
Osteoporosis causes bones to become brittle and prone to fractures from even minor trauma. When combined with muscle weakness and coordination problems, any fall or drop can result in serious fractures, particularly in the legs and hips. The tibia deformity suggests a significant fracture that could affect the resident's mobility and quality of life permanently.
For residents with dementia and multiple medical conditions, transfer accidents can be life-threatening. The physical trauma, combined with the stress and confusion of hospitalization, can accelerate cognitive decline and increase mortality risk.
Breakdown in Supervision Protocols
The inspection revealed critical failures in student supervision. The physical therapy student was working without adequate oversight, despite the facility's knowledge that this particular resident required specialized transfer techniques and close supervision.
According to federal nursing home regulations, students must be properly supervised at all times, particularly when working with high-risk residents. The facility's own protocols required two therapists to be present during this resident's therapy sessions, yet a single unsupervised student was attempting the transfer.
Immediate Facility Response
Following the incident, The Hillcrest of North Dallas took several corrective actions:
The physical therapy student was immediately removed from the facility and barred from returning. The facility contacted the student's school to inform them of the removal from the fieldwork program.
Staff received immediate re-education on mechanical lifts, gait belts, appropriate transfer training, and fall protocols. The training emphasized not moving residents after incidents and calling for nursing assessment immediately.
Enhanced Supervision Requirements
The facility implemented new policies requiring clinical supervisors to provide "close, direct supervision and oversight" to student clinicians in specific circumstances, including when making initial competence determinations and when students are learning new skills.
Under the revised policy, student clinicians must remain "in line of sight of the clinical supervisor when providing direct patient care," allowing supervisors to intervene and correct performance as necessary.
The Director of Rehabilitation and clinical instructors received training on these policy changes to ensure proper implementation.
Systemic Safety Concerns
The immediate jeopardy citation indicates that inspectors determined the facility's practices posed an immediate threat to resident safety. The citation specifically noted that "all residents who require assistance to be transferred have the potential to be affected," highlighting systemic risks beyond this single incident.
Transfer accidents are among the leading causes of serious injuries in nursing homes. Proper protocols require staff to assess each resident's transfer needs, use appropriate equipment, and ensure adequate staffing levels during transfers.
Ongoing Monitoring Requirements
The facility implemented a comprehensive monitoring system with the Director of Rehabilitation reviewing compliance daily for seven days, then weekly for four weeks, followed by monthly reviews for three months.
The Administrator and Director of Nursing will monitor the effectiveness of staff re-education efforts using the same schedule, with all concerns reported to the facility's Quality Assurance and Performance Improvement committee.
Industry Standards for Student Supervision
Physical therapy students in nursing home settings must work under licensed therapist supervision according to state practice acts and Medicare regulations. Students should never work independently with high-risk residents or attempt complex transfers without direct oversight.
Professional standards require that students demonstrate competency under supervision before being allowed increased independence. For residents requiring mechanical lifts or specialized transfer techniques, additional supervision protocols should be in place.
Medical Director Involvement
The facility's Medical Director met with the interdisciplinary team following the incident to review care protocols and ensure medical oversight of corrective measures.
Medical director involvement in serious incidents is required to ensure that clinical care decisions align with medical best practices and that resident safety remains the primary focus of all interventions.
The incident at The Hillcrest of North Dallas demonstrates the critical importance of proper student supervision in healthcare settings. When supervision breaks down, vulnerable residents face serious injury risks that could have been prevented through adherence to established safety protocols.
For residents and families, this case underscores the need to ask questions about student supervision policies and transfer protocols when evaluating nursing home care options.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Hillcrest of North Dallas from 2024-06-14 including all violations, facility responses, and corrective action plans.
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