HERTFORD, NC – BRIAN CENTER HEALTH & REHAB – HERTFORD

Based on observations, record reviews, staff interviews, resident interview, and Medical Doctor (MD) interview, the facility failed to identify a hazardous construction area adjacent to the sidewalk leading to the 200 Hall entrance of the building used by one of one sampled resident (Resident #1). The area did not restrict access or have any visual caution signage. Resident #1 navigated his motorized wheelchair down the sidewalk. When he attempted to turn the motorized wheelchair around on the sidewalk, one wheel fell off the pavement. Resident #1 fell into a construction trench filled with rocks and the wheelchair fell on top of him. Resident #1 was unable to telephone for help and laid in the trench until a passerby found him. Resident #1 was airlifted to the hospital where he was treated for fractures to his left femur and tibia which required surgery.

Immediate Jeopardy began on 3/7/21 when the facility failed to restrict resident access to an uneven sidewalk adjacent to a construction area and Resident #1 and his motorized wheelchair fell into a rock-filled construction trench. The resident was discovered by a passerby forty-five minutes after exiting the building and required emergency services and air lift to the hospital for treatment. The immediate jeopardy was removed on 3/26/2021 when the facility provided and implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level D (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) to ensure that the education and the monitoring systems put in place to remove the Immediate Jeopardy are effective.

A nurse note dated 3/7/21 revealed the nurse responded to a doorbell at the front entrance around 3:15PM. There was a young boy who told her a man turned over his wheelchair in the back of the building. The note further indicated the nurse went out to investigate, she found the resident off the pavement, in the rocks with the wheelchair on top of him. 911 had been dispatched at 3:33PM by the passerby, Emergency Medical Technician (EMT) arrived at 3:45PM. Four EMTs and fire department were needed to remove the wheelchair due to it weighing 400 pounds.