The incident at Rockcastle Health & Rehabilitation Center involved a resident with multiple sclerosis who had lived at the facility since 2016. Her care plan specifically required staff to use a mechanical lift with a green sling for all transfers.
On April 5, 2023, CNA4 was asked to help transfer the resident for her shower. Instead of using the mechanical lift that was already in her room, he manually lifted her from bed to shower chair and back again.
Three days later, another aide noticed the resident's left arm and hand were significantly weaker. On Monday morning, April 10, when staff took her to the shower room, they discovered extensive bruising on both arms above her armpits. Her shoulders were swollen and she cried out in pain.
X-rays revealed bilateral humeral neck fractures — both upper arm bones broken at the neck. The left fracture was comminuted, meaning the bone was fragmented into pieces. The right fracture was also comminuted and mildly displaced.
The resident was sent to the emergency room and returned wearing bilateral slings for comfort, along with prescription pain medication.
During the facility's investigation, CNA8 confirmed what happened during the April 5 shower. She had requested help getting the resident up with the mechanical lift, and CNA4 assisted. But even though there was a lift in the room, CNA4 performed a manual lift from bed to shower chair.
"CNA4 sat R29 up on the side of the bed and then performed a manual transfer, without using the mechanical lift as per the resident's care plan," CNA8 told investigators.
After the shower, CNA4 performed another manual transfer to get the resident back to bed.
The resident was assessed as totally dependent and requiring maximal assistance from two staff members for transfers. She was rarely or never understood and unable to be interviewed due to her dementia.
The facility's investigation concluded the fractures occurred from CNA4's manual lifting. During his interview, he acknowledged moving the resident manually and not using the lift as required by her care plan.
CNA4 was initially suspended, then terminated for his decision to ignore the care plan.
The facility's final investigation report stated: "The facility acknowledged staff (CNA 4) had not followed the resident's care plan related to transfers which caused R29's fractures."
Multiple staff members told investigators that all employees, including newly hired and agency staff, were educated about residents' care plans and transfer requirements.
"All staff, including CNA4, newly hired and agency staff, had been educated and were aware of R29's care plan requirement for the use of a mechanical lift for transfers," Registered Nurse 3 said during a phone interview.
The unit manager said CNA4 had been trained upon hire and re-educated about care plan interventions. "She felt CNA4 had been trained/educated and was fully aware that R29 required a mechanical lift for all transfers."
A restorative nurse said CNA4 "knew R29 was a total mechanical lift and knew the resident was care planned for the lift. She also stated CNA4 had been trained/educated and knew better."
The Director of Nursing said the facility's investigation determined the fractures were due to CNA4's failure to use the mechanical lift. "CNA4's actions went against facility policy and procedure and was not tolerated so, CNA4 was terminated."
This wasn't the only care plan failure at Rockcastle Health. Federal inspectors found a second resident whose oxygen therapy wasn't included in her care plan despite a physician's order for continuous oxygen at 2 liters per minute.
The resident had been admitted June 18, 2024, with diagnoses including chronic obstructive pulmonary disease. Her physician ordered oxygen therapy on June 19, but when inspectors reviewed her care plan dated the same day, no respiratory care plan existed.
The resident told inspectors she had been on oxygen therapy for about three years, including home oxygen before her admission.
During multiple observations between June 25-28, inspectors confirmed the resident was wearing her ordered oxygen via nasal cannula, with her concentrator set at 2 liters.
The Director of Nursing told inspectors she expected all oxygen orders to be placed on care plans. "She stated any physician order should be noted on the care plans."
But the resident's admission assessment failed to list oxygen under special treatments and procedures, and no care plan addressed her respiratory needs.
The Administrator said he expected all oxygen orders to be placed on residents' care plans and any changes should be updated accordingly.
These failures occurred at a facility where management claimed to prioritize care plan compliance. The current Administrator told inspectors that resident safety, transfers, and ensuring care plans were followed were discussed at every meeting, including daily morning meetings.
"Not following the residents' care plans was not an exception and was not tolerated," he said.
The restorative nurse said the current leadership was "very involved with resident care and safety to ensure staff followed residents' care plans." She emphasized that staff were routinely monitored and continuously re-educated about the importance of care plan interventions.
But the manual transfer incident showed how quickly harm could occur when care plans were ignored. As one nurse told investigators, "harm could occur easily and quickly if the care plan was not followed."
The facility had another resident who suffered multiple fractures from transfer incidents. R41 told inspectors he had fractured his right leg twice since living at the facility — once in 2020 and again in 2022.
The first incident happened when he was being transported in his wheelchair to be weighed without the right foot pedal attached. His leg got tired, dropped, and was pulled under the wheelchair, causing a fracture to his right distal femur.
The second incident occurred during a transfer from bed to wheelchair for a physician's appointment. Two CNAs assisting him didn't use a gait belt and rushed the transfer. The wheelchair brakes weren't on, he was sitting only on the edge of the seat, and the wheelchair kept rolling backwards as his leg twisted, resulting in a right tibial fracture.
The Medical Director said he expected staff to provide for residents' safety and well-being by following their care plans. But for the resident with dementia and multiple sclerosis, following that expectation came too late to prevent her bilateral arm fractures from a transfer that should never have been attempted manually.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rockcastle Health & Rehabilitation Center from 2024-06-29 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Rockcastle Health & Rehabilitation Center
- Browse all KY nursing home inspections