FORT WORTH, TX- FT WORTH SOUTHWEST NURSING CENTER

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37028

Based on interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of 3 residents reviewed for accidents.

LVN A failed to apply two footrests on a wheelchair prior to transporting Resident #1 for dialysis. The resident suffered an injury when the foot fell off the footrest two times. The resident was admitted to the hospital and diagnosed with a fracture of the left tibial tuberosity (area of bone just below the knee).

This failure could place residents at risk for serious injury or harm, decline in health, and decreased quality of life.

Findings included: Review of Resident #1’s MDS quarterly assessment, dated 06/04/23 reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included end stage renal disease (kidney failure) and cerebrovascular accident (stroke). The resident had moderately impaired cognition. The resident was totally dependent on staff for transfers.

Review of Resident #1’s undated care plan revealed the resident attended dialysis and required staff assistance for activities of daily living.

Review of Resident #1’s progress notes reflected: 06/05/23 9:47 PM General Progress Note Resident complained of bilateral foot pain and stated, when I was coming back from dialysis, my foot fell off the footrest of my wheelchair and turned inward. Foot assessment completed and no open areas noted. Tramadol (pain medicine) and Tylenol administered. Physician notified and bilateral foot x-rays ordered. – LVN B

06/06/23 5:14 AM General Progress Note

06/05/23 10:10 PM 911 arrived in building. Resident complained of legs hurting. Resident transported on stretcher with 2 attendants. DON notified. – LVN A

06/06/23 12:25 AM Hospital called and said x-rays were done with no fractures noted and pain medicine administered. – LVN C

06/7/23 1:25 PM General Progress Note Late Entry: Resident’s family here and she is concerned because resident is complaining of pain in both her legs. Family also concerned about resident missing a couple days of dialysis. Resident was medicated with pain medication about an hour ago. Family decided she wants the resident to be transferred to the emergency
room for evaluation and to get dialyzed. This writer notified charge nurse to get paperwork together to be transferred and to notify the Physician. – LVN D

Review of the X-ray results, dated 06/05/23, of the left knee for Resident #1 reflected:

Osteoarthritis (arthritis) of the left knee with no fracture.

Review of Computerized Tomography (CT) scan results, dated 06/09/23, of the lower extremities for Resident #1 reflected:

Osteopenia (soft bones) and fracture of the left tibial tuberosity (area of bone just below the knee).

An interview on 06/22/23 at 12:45 PM with the family of Resident #1 revealed on 06/05/23 the resident was placed in a manual wheelchair and pushed down the hall by LVN A. While in the wheelchair, the resident’s leg became stuck under the wheelchair. The family member said x-rays were completed (did not reveal a
fracture) and a CT scan was completed on 06/09/23 due to continued pain and the resident had a fracture.

Interviews on 06/22/23 at 2:00 PM and 4:35 PM with LVN A revealed on the morning of 06/05/23 she got a wheelchair for Resident #1 to transport her to the van for dialysis. She said the wheelchair had one footrest and she placed one foot on the footrest and the other leg she placed over the leg on the footrest. LVN A said while she was pushing the wheelchair, the resident’s foot fell off the footrest. LVN A said the foot did not go under the wheelchair. LVN A said she repositioned the foot back on the footrest. She said that the facility had additional chairs and additional footrests, but she did not go get one, because it was at the other station . LVN A said she did not do an incident report or tell anyone, because the foot just fell off the foot rest.

An interview on 06/22/23 at 2:20 pm with LVN B revealed she was waiting for evening shift report and the transport driver brought the resident back to the facility from dialysis. LVN B said the driver told her to make sure the wheelchair had two footrests the next time she went on transport. LVN B said later that evening on
06/05/23 the resident said her foot was hurting because her foot dropped off the footrest and turned inwards when the transport driver was bringing her back to the facility. LVN B said she medicated the resident, and
an x-ray was ordered.

An interview with the DON on 06/22/23 at 12:40 PM revealed he said Resident #1’s foot got caught on the wheelchair during dialysis transport on 06/05/23. He said the resident was sent to the hospital on 06/05/23 and returned to the facility with no fracture. He said the resident had a contusion (bruise). He said the
resident was sent to the hospital on 06/07/23 because she kept refusing dialysis. He said he did not know the resident was diagnosed with a fracture.

Review of the facility policy and procedure, Safety – Resident, dated May 2017 reflected:

It is the policy of this home that residents’ safety will be maintained during all aspects of care .

8. Be sure the resident is adequately secured when being transported. Protect resident’s extremities during
transportation.