Page Rehabilitation And Healthcare Center

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

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

heard the resident's knee make a popping sound. Resident #1 said she felt pain. An x-ray of the knee was ordered and was negative. Resident #1 was seen by a provider, and an appointment was made with an orthopedic specialist for 9/11/25.Review of the facility's investigation dated 10/22/25 revealed on 8/25/25

the restorative Certified Nursing Assistant (CNA) was providing restorative therapy of ROM to the resident's lower extremities. The CNA and the resident heard a pop while the ROM was being provided to the right leg. The resident complained of pain in the right knee and the CNA reported it to the nurse. The physician was notified and an Xray was ordered of the right knee. The Xray was obtained, and the results were negative. The resident continued to have slight discomfort and an orthopedic consultation was ordered. The resident went to the orthopedic specialist on 9/11/25 for her appointment. X-rays were completed and the resident was diagnosed with a closed fracture of the lateral tibial plateau. Review of Orthopedic Specialist visit note dated 9/11/25 revealed Resident #1's chief complaint was right knee pain. The progress note documented the resident was being seen for evaluation of right knee pain. Symptoms began with no identifiable injury (sudden onset). Symptoms include joint line pain and feelings of giving way. The patient describes symptoms as constant, present at rest, and aching. At their worst, symptoms are rated as 9 out of 10. Symptoms worsen with bearing weight. Symptoms improve with nothing. She had the following diagnostic studies: plain radiographs. The progress note documented, 8/25/25 participating in PT [Physical Therapy] and an aggressive therapy exercise was done/performed and notable pain thereafter with a pop.

X-ray obtained at the Orthopedic Specialist showed fracture of the right tibial plateau (the top part of a bone below the knee).On 10/27/25 at 9:50 a.m., in an interview Resident #1 said she had restorative therapy on 8/25/25. She said Restorative Aide Staff B started lifting her right leg, bending her knee and pushing her knee toward her face. She said it seemed too hard and she was pushing back. She was about to tell him to stop when she heard a pop and then had excruciating pain. She told him, You just hurt me.On 10/27/25 at 1:10 p.m. in an interview Restorative Aide Staff B said he was doing range of motion with Resident #1. He said her right leg was weaker than the left, so he would help her a little with the AROM. He said on 8/25/25

he had his hand under her knee while doing range of motion with her right leg. He said at that time they both felt a pop or a crack. He said resident #1 complained of pain and he reported it to the nurse.On 10/27/25 at 11:45 a.m., in an interview the Director of Rehabilitation said Resident #1 was referred to restorative nursing on 7/18/25. She recommended AROM. She said she did not recommend PROM. She said resident #1 should only be doing active range of motion. She said she doesn't recommend PROM to be done by restorative aides.On 10/27/25 at 2:48 p.m. in an interview the Director of Rehabilitation said a fracture could be a consequence of PROM. She said if there's osteoporosis or decreased strength, a fracture could occur.On 10/27/25 at 3:30 p.m. in an interview Physical Therapist Staff A said he would not expect the restorative aide to lift or have hands on the resident during AROM. He said the aides are not trained to do PROM. He said Resident #1's fracture was most likely because Resident #1 was pushing her leg out while the restorative aide was pushing against it. He said the restorative aide should not assist with AROM.

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