LAWRENCEBURG, KY- SIGNATURE HEALTHCARE AT HERITAGE HALL REHAB & WELLNESS

Review of the facility’s policy titled, Comprehensive Care Plans, dated 07/19/2021, revealed the
Person-Centered Comprehensive Care Plan would include how the facility would assist the resident to meet their needs, goals, and preferences.

MDS Assessment, revealed, under section G, Functional Status, that Patient #58’s transfers
required a two (2) person assist. Section P, Restraints, revealed limb restraints for the seatbelt was required.

Continued review of Resident #58’s medical record revealed he/she sustained a fall, on 07/23/2021 at 10:15 AM, which resulted in bruising above the eye. Resident #58 was placed into the wheelchair by Licensed Practical Nurse (LPN) #4, per the record, and she applied the seatbelt. However, the record stated the seatbelt was not applied correctly, which resulted in a fall with an injury. The record stated LPN #4 did not follow Resident #58’s CCP for placement of the seatbelt to Resident #58, while he/she was sitting in the wheelchair. The seatbelt was applied around the resident and attached to the cushion in the wheelchair.

Review of Resident #58’s CCP, under goals, dated 11/04/2020, revealed a restraint would be used when the resident was out of bed in a wheelchair, and the resident would be free of falls and/or would not sustain an injury related to falling through the next review date. Further review of the CCP, dated 11/19/2020, revealed a physical restraint was needed when the resident was in a wheel chair because of anxiety and decreased safety awareness, and the wheelchair seat belt could be used as the physical restraint. Continued review, under Approach, dated 12/02/2020, revealed an alarming seatbelt would be used, while the resident was in the wheelchair, for increased safety. Further review, under Approach, dated 07/23/2021, after the fall, revealed staff would receive a proper demonstration on how to utilize the wheelchair seatbelt.

Interview with Licensed Practical Nurse (LPN) #4, on 10/28/2021 at 3:58 PM, revealed Resident #58 asked the nurse to get up. She stated the resident had not been out of bed for months. LPN #4 stated, with the assistance of an aide, they placed the resident into the wheelchair. She stated she applied the seat belt around the resident sitting in the wheelchair. LPN #4 stated she thought the seat belt was in place; however, the resident slid out of the chair. She further stated the seat belt was applied wrong. She stated she did not realize the seatbelt was attached to the cushion in the wheelchair, which made the resident unsecured. LPN #4 stated she had not followed the resident’s CCP.