BRODHEAD, KY - State inspectors have cited Rockcastle Health and Rehabilitation Center for serious transfer safety violations that resulted in multiple fractures to residents, with investigators determining that staff members failed to follow proper care protocols during transfers from beds to wheelchairs.
Repeated Transfer Incidents Lead to Serious Injuries
The facility faced immediate jeopardy citations following an investigation into incidents involving two residents who sustained fractures during routine transfers. The most concerning case involved a resident who experienced two separate transfer-related injuries over the span of nearly two years, highlighting systemic failures in following established safety protocols.
The first incident occurred in August 2020 when a resident with an above-knee amputation was being transported in a wheelchair without proper foot support. During transport, the resident's remaining leg became fatigued and dropped beneath the wheelchair, causing the limb to be pulled under the chair and resulting in a fracture of the distal right femur. Medical imaging revealed not only the fracture but also a 2-centimeter gap between bone fragments and partial dislocation of the proximal femur.
The same resident experienced a second transfer-related injury in April 2022 when two male nursing assistants were transferring him from bed to wheelchair for a medical appointment. According to the resident's account, the staff members were "rushing" the transfer and failed to use a gait belt, which is standard safety equipment for transfers. During this incident, the wheelchair wheels were not locked, and as staff attempted to reposition the resident, his leg twisted, resulting in a displaced fracture of the right tibial tuberosity.
Failure to Follow Mechanical Lift Requirements
A separate incident involved a resident with multiple sclerosis and dementia who required total assistance with transfers using a mechanical lift according to her care plan. Despite clear documentation requiring the use of a mechanical lift with a specific green sling, a nursing assistant manually lifted the resident during a shower transfer in April 2023.
The manual transfer, which violated the resident's established care plan, resulted in bilateral humeral neck fractures - breaks in both shoulder areas. The injuries went undetected for five days until staff noticed significant bruising and swelling during a routine shower. X-rays confirmed comminuted fractures in both shoulders, with the hospital emergency department physician specifically noting the possibility of neglect or abuse given the resident's bedbound status and lack of reported trauma.
Medical Consequences and Safety Protocols
Transfer-related injuries in nursing home settings can have devastating consequences, particularly for elderly residents with multiple health conditions. Femur fractures, like those experienced by the first resident, often require surgical intervention and extended rehabilitation periods. For residents with pre-existing mobility limitations, such injuries can permanently reduce functional capacity and independence.
Bilateral shoulder fractures, as occurred in the second case, are particularly serious for residents who depend on upper body strength for any remaining mobility or daily activities. These injuries typically result in significant pain, reduced range of motion, and increased dependence on staff for basic care needs.
Proper transfer protocols exist specifically to prevent these types of injuries. Gait belts provide secure handhold points for staff and help distribute lifting forces across a resident's torso rather than concentrating stress on limbs or joints. Mechanical lifts are designed to safely support residents who cannot bear their own weight during transfers, eliminating the risk of staff dropping or mishandling the resident.
When care plans specify the use of mechanical lifts, this determination is based on comprehensive assessments of the resident's physical capabilities, cognitive status, and safety needs. Deviating from these protocols not only violates professional standards but also places residents at significant risk of injury.
Industry Standards and Best Practices
Standard nursing home protocols require that all transfers be performed according to each resident's individualized care plan. For residents requiring mechanical lifts, staff must receive specific training on equipment operation and safety procedures. The use of gait belts is considered fundamental safety practice for any transfer involving physical assistance.
Transfer safety protocols also mandate that wheelchair wheels be locked during transfers and that appropriate support devices, such as foot pedals, be properly positioned before movement. These seemingly minor details can prevent serious injuries when residents have limited mobility or cognitive awareness.
Staff members performing transfers should always work within their scope of practice and training level. Personal Care Assistants, for example, are typically limited to providing assistance under the direct supervision of licensed nursing staff and should not independently perform complex transfers.
Investigation Findings and Facility Response
The facility's investigation into the mechanical lift incident determined that the nursing assistant's decision to manually transfer the resident rather than use the required mechanical lift directly caused the bilateral shoulder fractures. The staff member was initially suspended and later terminated for failing to follow the resident's care plan.
However, the broader pattern of transfer-related incidents suggests systemic issues beyond individual staff failures. The facility acknowledged that staff did not follow established care plans and protocols, indicating gaps in training, supervision, or accountability measures.
Additional Issues Identified
Inspectors documented several other concerning practices during their investigation:
Training and Oversight Deficiencies: The facility could not demonstrate adequate training records for some staff members involved in the incidents, and there was insufficient evidence of ongoing competency validation for transfer procedures.
Care Plan Compliance: Multiple instances were identified where staff failed to reference or follow residents' established care plans, which contain specific instructions for safe transfers based on individual assessments.
Equipment Management: Issues with wheelchair maintenance and proper use of assistive devices, including failure to ensure foot pedals were properly positioned before transport.
Documentation Gaps: Inconsistent reporting and documentation of transfer procedures and any variations from established protocols.
The facility provided an immediate jeopardy removal plan, which was validated by state inspectors, though the investigation revealed that proper corrective measures should have been implemented much earlier to prevent the pattern of transfer-related injuries.
These violations highlight the critical importance of consistent adherence to transfer safety protocols in nursing home settings, where residents are particularly vulnerable to injury due to age-related frailty, multiple medical conditions, and cognitive impairments that may prevent them from protecting themselves during transfers.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rockcastle Health and Rehabilitation Center from 2024-06-29 including all violations, facility responses, and corrective action plans.
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