LIBERTY, KY - A June 2024 federal inspection at Liberty Care and Rehabilitation Center revealed staff failed to implement proper safety protocols, resulting in a severe finger injury from wheelchair equipment and inadequate fall prevention measures for cognitively impaired residents.
Wheelchair Accident Results in Resident Finger Laceration
During transport to her room, a resident identified as R37 sustained a significant finger laceration when her hand became caught in the spokes of a specialty wheelchair. The incident occurred as staff members were transferring the resident back to her bedroom to provide care.
According to inspection documents, the injury was serious enough to require emergency room treatment at University Hospital. The Director of Nursing reported that staff discovered the laceration after completing the transfer to the resident's bed, noting that "her finger was lacerated and injured, and the injury was caused by the wheelchair."
The incident highlighted several critical safety failures. Despite the facility's claims that staff received training on equipment use, administrators could not provide documented evidence that personnel were trained on the specific Evolution wheelchair model involved in the accident. This gap in training protocols left staff unprepared to safely operate specialized equipment.
The wheelchair design itself presented hazards that went unaddressed. The exposed wheel spokes created an entrapment risk that staff failed to identify or mitigate. Medical protocols require healthcare facilities to assess equipment for potential hazard points and implement protective measures before use with patients. Finger and hand injuries from wheelchair mechanisms can result in permanent damage, including tendon lacerations, nerve damage, bone fractures, and loss of function.
Facility administrators acknowledged that R37 exhibited decreased cognition and sometimes demonstrated non-compliant behaviors, including attempts to control her wheelchair independently. The resident's care plan documented these behaviors, and staff discussed them during shift changes. However, the facility failed to implement specific safety interventions to address her tendency to grab at the wheelchair wheels during transport.
The facility's response to the injury revealed systemic gaps in proactive safety management. Only after R37's accident did maintenance staff install spoke covers on the wheelchair. Subsequently, the facility placed protective covers on all specialty wheelchairs and evaluated all residents using wheelchairs for positioning and safety concerns. These measures should have been standard practice before any incidents occurred.
Inadequate Fall Prevention for Cognitively Impaired Resident
The inspection identified failures in fall prevention protocols for Resident R29, who experienced a documented fall on June 10, 2024. R29, admitted in April 2022 with diagnoses including dementia and Alzheimer's disease, had a BIMS cognitive assessment score of six out of 15, indicating severe cognitive impairment.
Licensed Practical Nurse 6 discovered R29 on his knees beside his closet door. The resident reported he fell while searching for something in the closet. The fall resulted in a skin tear to his right forearm that required wound care, including cleaning with normal saline, application of triple antibiotic ointment, and daily dressing changes with gauze wrapping.
The facility's response to this fall violated fundamental principles of fall prevention management. Assessment records showed R29 required partial to moderate assistance with multiple activities, including transfers from chair to bed, sit-to-stand movements, and toileting. He was assessed as having poor safety awareness and a documented history of falls. His care plan, revised on May 10, 2024, identified him as a fall risk with interventions including bathroom lighting at night, non-slip socks, assistance to the toilet as needed, and limited assistance with transfers.
Despite these existing interventions, R29 fell again on June 10, 2024. Standard nursing practice requires immediate care plan updates following any fall incident to address contributing factors and prevent recurrence. The care plan should have been revised to include new interventions specific to the circumstances of this fall, such as increased monitoring during periods when the resident might attempt to access his closet, environmental modifications to reduce fall hazards near storage areas, or alternative systems for helping him retrieve items safely.
However, the facility's care plan showed no documented evidence of new interventions following the June 10 fall. This failure to update fall prevention strategies left R29 at continued risk for additional injuries. Falls in residents with severe cognitive impairment carry particularly serious consequences, including hip fractures, head trauma, internal bleeding, and progressive functional decline that can lead to loss of mobility and independence.
Medical Implications of Safety Protocol Failures
These violations demonstrate breakdowns in fundamental patient safety systems that healthcare facilities must maintain. Wheelchair-related injuries are preventable through proper equipment assessment, staff training, and individualized safety planning based on each resident's physical and cognitive capabilities.
For residents with cognitive impairment, the risk of wheelchair injuries increases significantly. Patients with dementia may not remember safety instructions, may attempt to control equipment inappropriately, or may place their hands in dangerous positions without recognizing the hazard. Healthcare staff must anticipate these behaviors and implement protective measures proactively.
Fall prevention requires systematic, individualized assessment and ongoing reassessment. Each fall incident provides information about risk factors that must be addressed through updated interventions. The failure to revise care plans after falls represents a fundamental breakdown in the clinical reasoning process that nursing staff must employ to protect vulnerable residents.
Skin tears in elderly residents with cognitive impairment present serious health risks. These wounds heal slowly due to age-related changes in skin integrity and cellular repair mechanisms. Complications can include infection, which may progress to cellulitis or sepsis in immunocompromised individuals. The presence of dementia complicates wound care, as residents may interfere with dressings or fail to report worsening symptoms.
Respiratory Care Equipment Management Deficiency
Inspectors identified additional safety concerns regarding oxygen therapy management. Resident R58, who required continuous oxygen at two liters per minute via nasal cannula for congestive heart failure, had oxygen tubing that lacked required date labeling.
The facility's own policy, revised May 30, 2024, specified that oxygen tubing must be changed monthly or as needed, with dating to track replacement schedules. During observations on June 10 and June 11, 2024, R58's oxygen tubing displayed no date marking, making it impossible to verify compliance with the monthly replacement requirement.
Oxygen tubing that remains in use beyond recommended replacement intervals can accumulate bacterial contamination, develop material degradation that affects oxygen delivery, or become occluded with moisture condensation. For residents with heart failure who depend on supplemental oxygen to maintain adequate tissue oxygenation, equipment failures can result in respiratory distress, cardiac complications, or acute decompensation requiring hospitalization.
Nursing leadership acknowledged the dating requirement but revealed inconsistent implementation, particularly noting that new admissions set up with oxygen often had undated tubing. This systematic gap in equipment management protocols placed multiple residents at potential risk.
Administrative Accountability and Expectations
The Administrator and Medical Director both stated expectations that staff would provide safe environments and follow proper safety procedures. However, the documented violations revealed significant gaps between stated expectations and actual practice implementation.
The Corporate Nurse Consultant emphasized the importance of watching residents during transport and transfers to prevent injuries, stating staff should follow all safety procedures. Yet the wheelchair incident demonstrated staff was neither adequately trained on specialized equipment nor consistently monitoring residents for safety risks during routine care activities.
Multiple nursing staff members, including the Unit Manager and MDS Nurse, acknowledged that care plans should be updated immediately following falls with new interventions to prevent recurrence. The Director of Nursing stated she performed random reviews to ensure staff revised care plans appropriately. Despite this stated oversight process, R29's care plan remained unchanged after his documented fall.
Additional Issues Identified
The inspection revealed deficiencies beyond the major violations detailed above. The facility's medication management system experienced delays in obtaining prescribed medications, with one resident's ordered rifampin not delivered until four days after the physician's order was written. Such delays in medication availability can compromise treatment effectiveness and resident health outcomes.
Facility Response Measures
Following R37's wheelchair injury, the facility implemented reactive safety measures including installation of spoke covers on all specialty wheelchairs and comprehensive safety evaluations for all residents using wheelchairs. While these actions addressed the immediate hazard, they highlighted the absence of proactive safety assessment protocols that should have prevented the initial injury.
The violations documented in this inspection demonstrate patterns of reactive rather than preventive safety management, inadequate staff training on specialized equipment, inconsistent implementation of facility policies, and failures to update care plans based on resident incidents and changing needs.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Liberty Care and Rehabilitation Center from 2024-06-14 including all violations, facility responses, and corrective action plans.
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