Colonial Care Center

F 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Resident 1's X-ray Report, dated 1/3/2026 and timed at 12:01 p.m., the X-ray report indicated Resident 1 had a fracture of the right distal femur. During a review of Resident 1's Licensed Nurses Note, dated 1/3/2026 and timed at 3:43 p.m., the note indicated Resident 1 was transferred to a GACH due to a fracture. During a review of the GACH's Emergency Department's History of Present Illness (HPI), dated 1/3/2026, the HPI indicated Resident 1 present to the emergency room with swelling and deformity of the right distal thigh, an X-ray indicated an acute distal femur fracture. The HPI indicated Resident 1 was admitted to the GACH for pain control, immobilization, an orthopedic (a medical specialist focusing on the muscles and bones) surgical evaluation, monitoring for complications including bleeding, thromboembolism and skin breakdown. During a review of the GACH's Orthopedic Consultation report, dated 1/5/2026, and timed at 9:37 a.m., the Orthopedic Consultation indicated Resident 1's injury was likely due to malunion (a broken bone that healed in an abnormal, misaligned position) and surgery was not recommended due to Resident 1's dementia and non-ambulatory status. The report indicated Resident 1 was stable for discharge from an orthopedic standpoint. During an interview on 1/28/2026 at 4:40 p.m., Certified Nursing Assistant (CNA) 1 stated Resident 1 required a two-person assist for care. On 1/2/2026 she and CNA 2 provided care to Resident 1 during the 3 p.m. to 11 p.m., shift. CNA 1 stated sometime during the evening (time unknown), she and CNA 2 noticed Resident 1's right knee was bending weirdly. CNA 1 stated they (CNA 1 and CNA 2) informed LVN 1, LVN 1 repositioned Resident 1 and accidentally bumped the resident's right knee on bed frame. During an interview on 1/29/2026 at 10:13 a.m., LVN 1 stated on 1/2/2026, at around 9:30 p.m., while making rounds, she found Resident 1 at the edge of the right side of her bed, with her right foot hitting the bed's footboard. LVN 1 stated she knew Resident 1 was a two-person assist but everyone was busy caring for other residents', to prevent Resident 1 from falling she decided to reposition Resident 1 without assistance. LVN 1 stated she used a draw sheet (a small, folded bed sheet or specialized fabric placed across the middle of a mattress, covering the area between a patient's upper back and thighs.

Primarily used to reposition, lift, or transfer patients) to pull Resident 1 up while Resident 1's right leg was crossed over the left leg; both legs were straight. LVN 1 stated Resident 1 was centered in the middle of the bed and as she proceeded to turn Resident 1 toward the left side of the bed, Resident 1 moved her legs, and her right knee hit the bed frame on the bottom of her bed that was exposed because the mattress did not cover the bed frame completely. LVN 1 stated she noticed Resident 1 was grimacing, moaning, and she observed redness and swelling on the resident's her right knee. During an interview on 1/29/2026 at 11:54 a.m., the Director of Nursing (DON) stated LVN 1 should have called for help if Resident 1 required a two-person assist. During a review of the facility's undated P/P, titled, Positioning & Moving Residents the P/P indicated before moving or lifting a resident, staff members were to assess the resident's physical abilities, mobility limitation in joints and muscles, strength, awareness of surroundings, and ability to follow directions. Staff members will use maximum precautions when moving or lifting residents, obtain assistance from other professional as needed.

Event ID:

Facility ID:

If continuation sheet