BRODHEAD, KY - Federal inspectors found serious safety violations at Rockcastle Health and Rehabilitation Center after multiple residents sustained fractures due to improper transfer procedures and inadequate staff training, with one resident experiencing two separate leg fractures within two years.
Resident Suffers Two Leg Fractures Due to Unsafe Transfer Practices
The most serious violations centered around a resident identified as R41, who sustained two separate fractures to his right leg between August 2020 and April 2022. Both incidents occurred during routine transfers that failed to follow established safety protocols.
The first incident occurred in August 2020 when a certified nursing assistant (CNA) was transporting R41 in his wheelchair to be weighed. According to the resident's account, his wheelchair couldn't fit through the door to the scale area due to anti-tippers, so the CNA took him to another wing. During transport back to his room, R41's leg became tired and dropped beneath the wheelchair before he could alert the staff member, causing the leg to be pulled under the chair and overextended.
Medical imaging revealed significant injuries from this incident. While initial X-rays showed no fracture, a CT scan performed eight days later revealed an insufficiency fracture of the distal right femur. Hospital records from September 8, 2020, confirmed a fracture of the distal right femur with a 2-centimeter gap between fracture fragments and partial dislocation of the proximal femur.
The second incident occurred in April 2022 during a bed-to-wheelchair transfer as R41 prepared for a medical appointment. The resident reported that two male CNAs were "rushing" the transfer and failed to use required safety equipment. According to R41's account, the staff did not use a gait belt, the wheelchair wheels were not locked, and he was positioned only on the edge of the seat when the transfer began. During the improper transfer, his leg twisted, resulting in a displaced fracture of the right tibial tuberosity.
Hospital documentation from the second incident noted that the mechanism of trauma was recorded as a fall or jump, and the resident stated "the aides who had been assisting him transferred him to the wheelchair too quickly and he went backwards."
Bilateral Arm Fractures from Manual Lifting Violation
In a separate case demonstrating systemic safety failures, inspectors found that resident R29 sustained bilateral humeral neck fractures in April 2023 when staff performed manual transfers instead of using required mechanical lifting equipment.
R29, who had dementia and multiple sclerosis, was assessed as requiring total care with two staff members and a mechanical lift with a green sling for all transfers. Despite clear care plan requirements, facility investigation revealed that on April 5, 2023, CNA4 manually lifted R29 from bed to shower chair and back, completely bypassing the required mechanical lift that was present in the room.
The violations weren't discovered until five days later when staff noticed yellow and purple bruising on both of R29's upper arms and clavicle area during bathing. Portable X-rays confirmed recent bilateral humeral neck fractures. Hospital emergency department staff considered the possibility of neglect or abuse, as R29 was bedbound and the fractures occurred without any reported trauma.
The facility's investigation concluded that CNA4 acknowledged moving R29 manually and not following the care plan. The staff member was initially suspended and then terminated. However, the damage had already occurred - R29 required bilateral arm slings and narcotic pain medication for the preventable injuries.
Medical Context: Why These Violations Matter
Proper transfer techniques are fundamental to nursing home safety because residents often have multiple risk factors for fractures, including osteoporosis, muscle weakness, and medications that affect bone density. When staff fail to follow established protocols, the consequences can be severe and life-altering.
Transfer-related injuries represent a significant cause of morbidity in nursing home settings. For residents with limited mobility like R41 and R29, fractures can result in decreased functional capacity, chronic pain, and reduced quality of life. Hip and femur fractures, in particular, are associated with increased mortality rates and functional decline in elderly populations.
Mechanical lifts and transfer aids are specifically designed to distribute weight safely and prevent the type of sudden movements that can cause fractures. When staff bypass these safety measures, they expose vulnerable residents to unnecessary risk of serious injury. The use of gait belts during transfers provides additional security and allows staff to maintain better control during the movement process.
For residents requiring oxygen therapy, equipment maintenance directly impacts respiratory function. Dusty or clogged filters can reduce oxygen flow efficiency and potentially introduce contaminants into the respiratory system, particularly concerning for residents with chronic obstructive pulmonary disease (COPD) like R242.
Respiratory Care Equipment Maintenance Failures
Inspectors also identified violations in respiratory care when they observed that resident R242's oxygen concentrator filter was covered in dust. R242, who was admitted with diabetes and COPD, required continuous oxygen therapy at 2 liters per minute via nasal cannula.
The resident reported that the filter had not been cleaned since admission on June 18, 2024 - more than a week before the inspection. Staff interviews revealed confusion about responsibility for filter maintenance, with some nurses believing the oxygen company was solely responsible while others acknowledged that cleaning could be done as needed when dirty filters were observed.
Proper oxygen equipment maintenance is essential for residents with respiratory conditions. Dirty filters can impede oxygen flow, reduce equipment efficiency, and potentially introduce contaminants into the breathing circuit. For residents dependent on supplemental oxygen, any compromise in equipment function can lead to respiratory distress or inadequate oxygenation.
Staff Training and Protocol Adherence Gaps
The violations revealed significant gaps in staff training and protocol adherence. Despite having written policies requiring mechanical lifts for certain residents and proper transfer techniques, multiple staff members failed to follow established procedures.
The facility's gait belt policy specified that all CNAs, licensed nurses, and therapists received education on proper use during their training, yet staff repeatedly failed to use this basic safety equipment. Similarly, despite clear care plan requirements for mechanical lift usage, staff chose to manually transfer residents, resulting in serious injuries.
Investigation records showed that witness statements from involved staff contained inconsistencies and, in some cases, attempts to attribute resident injuries to the residents themselves rather than acknowledging procedural failures.
Additional Issues Identified
Beyond the major transfer and respiratory care violations, inspectors documented several other compliance issues. The facility failed to develop comprehensive care plans that included oxygen therapy requirements despite physician orders for continuous oxygen use. Staff interviews revealed inconsistent understanding of equipment maintenance responsibilities and infection control procedures related to respiratory equipment.
The facility had previously received citations for similar transfer-related issues, indicating ongoing challenges with implementing and maintaining safe transfer practices across all shifts and staff members.
These violations demonstrate the critical importance of consistent staff training, clear protocols, and adequate supervision to ensure resident safety in nursing home settings. When basic safety measures are overlooked or bypassed, the consequences for vulnerable residents can be severe and long-lasting.
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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