The June 9 accident at Liberty Care and Rehabilitation Center sent the 89-year-old woman to two hospitals. Emergency room doctors found a 2-centimeter laceration that exposed bone in her left index finger, plus another 1.5-centimeter cut at the joint. X-rays revealed "a significantly displaced comminuted angulated fracture" — meaning the bone was broken at an angle into several pieces.
Staff knew the resident grabbed wheelchair spokes when she didn't want to be moved. They knew she had severe dementia and couldn't follow simple instructions. But managers never created safety interventions to prevent injury.
"She would grab the wheels of the chair to resist being moved," Licensed Practical Nurse 5 told inspectors. "It would be important for staff to be aware of this behavior in order to ensure the resident did not have her hands in the wheel spokes prior to moving the resident in the chair."
The facility only added spoke covers to the woman's wheelchair two days after the accident.
State Registered Nurse Aide 4 witnessed the incident. She saw the resident place her hands in the wheelchair spokes, then watched another aide tell her to move them to her lap. The resident complied. But when staff transferred her to bed minutes later, they noticed her finger "was crooked."
"R37 tended to grab the spokes part of the wheelchair when she did not want staff to move her," the aide said.
State Registered Nurse Aide 10, who was pushing the wheelchair, had worked at the facility for only two months and "did not know R37 well." She told inspectors she pulled the wheelchair backward because it was "hard to push forward" and the resident wore a protective boot with no footrests on the chair.
The resident's care plan from May listed her goal as regaining "ability for locomotion on and off the unit." It mentioned following physical therapy recommendations for "correct use of the resident's mobility chair" but never specified what those recommendations were. Despite documenting that she was "non-compliant with Physician's Orders," the care plan included no safety measures for her wheelchair-grabbing behavior.
Licensed Practical Nurse 3, the unit manager, said the resident "should have been care planned for this behavior of grabbing the wheels, and interventions should have been in place to prevent injury related to this prior to the incident."
The MDS Nurse, responsible for most care plan updates, said she "was not made aware of R37's tendency to grab the wheels and spokes of her wheelchair and therefore she did not revise the resident's care plan to address this."
But multiple staff members knew about the behavior. The Director of Nursing said "any non-compliance was reported during shift changes," though she claimed ignorance of the specific wheel-grabbing habit.
Three days after the wheelchair accident, another resident with dementia fell while searching his closet. Staff found the 85-year-old man on his knees beside the closet door with a skin tear on his right forearm. His care plan identified him as a fall risk with "poor safety awareness," but managers added no new interventions after the fall.
Licensed Practical Nurse 6, who found him, said "if there was a fall, there should be a new intervention placed on the care plan in order to prevent the resident from falling again."
The facility also failed to provide basic hygiene care. One resident complained staff rarely brushed her teeth, leaving white crust on her lips and mouth. She said she received bed baths only twice weekly and genital care only after bowel movements.
Another resident wore the same dark gray shirt for two consecutive days during the inspection. He had long, dirty fingernails, hadn't been shaved, and his teeth were covered with gray film.
State nursing aides told inspectors residents should receive showers twice weekly, daily oral care, and clothing changes every day. The Administrator said staff should check residents every two hours for incontinence care.
The Director of Nursing acknowledged care plans needed "necessary safety interventions" and should be "revised as needed in order to ensure a safe and comfortable environment for the residents."
A third resident with severe dementia continued wandering into other residents' rooms and going through their belongings, despite being care planned for this behavior since December. One resident said she had to throw away cookies after the wandering resident touched them. Another hid her perfumes.
The MDS Nurse said she was unaware the behavior continued because staff weren't documenting it in the computer system. "If I had known R49 was still exhibiting behaviors of entering other residents' rooms she would have had staff do a stop and watch," she said.
The Administrator called the situation "unfair for other residents to have their room entered and their belongings gone through or taken."
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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