Liberty Care & Rehabilitation Center
Liberty Care & Rehabilitation Center in Liberty, KY — inspection on June 14, 2024.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview with the Corporate Nurse Consultant (CNC), on 06/14/2024 at 9:24 AM, she stated she was notified the morning of the incident regarding R37's injury.
The CNC stated the resident's finger was injured at some point during her transport to her room to provide care.
She stated R37 should have been care planned for grabbing the wheels during transport in order for staff to watch for this.
She further stated she expected staff to follow all safety procedures, and watch residents during transport and transfers to avoid injuries.
The CNC stated it was important to provide a safe and comfortable environment for residents and to prevent accidents and injury to residents and staff.
The State Survey Agency Surveyor attempted to contact the Provider at the University Hospital on 06/14/2024 at 7:55 AM.
During a conversation with the emergency department's Case Manager, she stated she would have the Provider call. No return call was received.
During an interview with the Administrator, on 06/14/2024 at 9:24 AM, she stated she was notified of R37's injury by the DON.
The Administrator stated the injury was caused by the wheelchair.
She further stated after the incident the facility assessed all residents in wheelchairs for positioning and safety; and spoke covers had been placed on all specialty wheelchairs.
The Administrator stated it was her expectation staff ensure important safety measures were in place in order to provide a safe and comfortable environment for residents.
She stated this was important to prevent accidents and injury to residents and staff.
During an interview with the Medical Director, on 06/14/2024 at 1:10 PM, he stated he was informed about the incident regarding R37. He stated he was told the aide pulled the wheelchair in the opposite direction and the resident's fingers were caught in the wheelchair spokes. He further stated he ordered the resident to be transferred to the ER.
The Medical Director stated it was his expectation staff provide for the safety and well-being of the residents.
185408
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 185408 B.
Wing 06/14/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Liberty Care and Rehabilitation Center 616 S Wallace Wilkinson Blvd Liberty, KY 42539
Review of R37's electronic medical record (EMR) Face Sheet revealed the facility admitted the resident on 12/09/2022, with diagnoses which included Alzheimer's disease, severe dementia with agitation, mood
05/24/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of two (2) out of fifteen, indicating severe cognitive impairment.
Additional review revealed the facility assessed the resident as requiring substantial/maximal assist of two (2) for chair to bed, and bed to chair transfers and as independent with locomotion in a specialized wheelchair.
Review of R37's Comprehensive Care Plan (CCP), revised 05/24/2024, revealed a focus of Activities of Daily Living (ADL) with a goal stating the resident will regain ability for locomotion on and off the unit.
Interventions related to locomotion included following Physical Therapy's (PT) and Occupational Therapy's (OT) recommendations related to ADLs and the correct use of the resident's mobility chair; and to allow the resident extra time to complete ADLs.
However, the care plan interventions did not list PT and OT recommendations for the correct use of the mobility chair.
Additional review of R37's CCP, revised 05/24/2024, revealed a focus on behaviors, including demonstrates non-compliance with Physician's Orders and/or plan of care.
The long term goal revealed the resident's preferences will be honored to the extent that non- compliance with the plan of care will not result in injury to self or others.
Interventions created on 02/11/2024 included encourage resident to actively participate in the care plan and decision making; and encourage the resident's participation with care.
Additional review of the CCP revealed the facility did not address the resident's habit of grabbing onto the wheelchair wheels and not moving her feet when being transported by staff in her specialized wheelchair.
There were no safety interventions to prevent injury related to this behavior.
Review of the facility's Event Report - Change in Condition, dated 06/09/2024 at 12:52 AM, signed by Licensed Practical Nurse (LPN) 5, revealed while staff assisted R37 to her room for routine care, the resident's finger was caught in the wheel spokes of the mobility chair causing injury to her left index finger. LPN5 assessed R37 as having a skin tear with moderate blood noted.
The resident's responsible party and physician were notified and the resident was transferred by emergency medical services (EMS) to the Hospital for further evaluation.
Review of R37's local Hospital Emergency Department's Progress Note, dated 06/09/2024 at 1:38 AM, revealed physicians found (1) laceration, measuring 2.0 centimeters (cm) which exposed the bone in the proximal region of the finger, and another measuring 1.5 cm which was located at the medial joint.
Per the Note, the resident was subsequently transferred to the University Hospital Emergency Department to seek evaluation by a hand specialist.
Review of R37's University Hospital Physician Progress Notes, dated 06/09/2024 at 1:38 AM, revealed the patient (resident) presented to the emergency department for a higher level of care from an outside hospital to evaluate the left finger injury.
The patient sustained an open fracture to her left index finger, with an approximate 2.0 cm laceration to the metacarpophalangeal joint, with deformity of the left hand noted.
185408
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 185408 B.
Wing 06/14/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Liberty Care and Rehabilitation Center 616 S Wallace Wilkinson Blvd Liberty, KY 42539