NEWPORT, TN – NEWPORT HEALTH AND REHABILITATION CENTER

Based on facility policy review, medical record review and interview, the facility failed to prevent accidents for 1 resident (Resident #259) of 4 residents reviewed for accidents. The facility failed to transfer Resident #259 with the care planned intervention for transfer. The facility’s failure resulted in a fracture of the resident’s proximal left tibia (upper part of the shin bone) and Harm for Resident #259.

Interview with the PA on 6/7/2021 at 3:30 PM, confirmed CNA #1 had transferred Resident #259 from the bed to the wheelchair without use of the mechanical lift and without assist from another staff member. The PA stated when the resident complained of pain, the morning of 10/10/2021, an x-ray had been obtained which showed a tibial plateau fracture (a break in the larger lower leg bone below the knee). The PA confirmed the resident was unable to bear weight on his legs, before and after the leg fracture. The PA further stated she believed CNA #1’s failure to follow the care planned intervention for a lift transfer on 10/9/2020 had caused Resident #259’s leg fracture.

Interview with Licensed Practical Nurse (LPN) #4 on 6/8/2021 at 8:25 AM, confirmed she had worked the day shift on 10/10/2020 and assessed Resident #259 for a complaint of pain. She stated the resident told her he had gotten hurt the previous day, during a transfer to the wheelchair on 10/9/2020. She stated she notified the PA and obtained an x-ray. LPN #4 stated the resident required a mechanical lift for transfers.