Health inspection·June 20, 2024

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure two staff assisted in transferring a resident safely while using a mechanical lift. This failure resulted in R2 falling from the mechanical lift to the floor, sustaining a right tibia fracture and an occipital contusion and transfer to the emergency department. This Applies to 1 of 5 residents (R2) reviewed for falls and accidents in a sample of 9. A care plan initiated on 10/30/2023 showed that R2 needs two staff members to assist with ADLs (Activities of Daily Living), including transfers from bed to wheelchair and vice versa. The MDS (Minimum Data Set), dated 11/22/2023, showed that R2 is cognitively intact and dependent on ADLs, requiring two or more staff members to complete activities such as transfers, dressing, personal hygiene, and bathing. A review of R2's face sheet and physician's progress notes dated 01/24/2024 showed R2 was an [AGE] year-old admitted to the facility initially on 05/01/2023 with diagnoses including muscular dystrophy, osteoarthritis, history of falls, disease of the spinal cord, history of multiple traumatic fractures, lack of coordination, vitamin D deficiency, progressive weakness, wheelchair-bound, and chronic obstructive pulmonary disease. On 06/13/2024 at 01:04 PM, R2 was in bed, alert, oriented to person, place, and time, and was interviewable. R2 said, V12 (Certified Nursing Assistant) put him in a mechanical lift by herself, and the sling was smaller to him. R2 said when she lifted him from the bed, his groin hurt, and he told V12 to take the sling off. R2 said V12 played around with the sling and took the mechanical lift near the door where his power wheelchair was, and he fell from the mechanical lift and broke his right leg and blood was coming from the back of his head. R2 said V12 ran outside the room and told other staff that she had dropped him and staff had come to assist him. Nursing progress notes dated 01/21/2024 showed that at 8:40 AM, R2 had a witnessed fall during transfer, causing injury to the head (occipital region) and right knee pain. The nursing progress notes further showed that R2 was sent to the emergency department for evaluation. R2's hospital emergency department Physician history and physical dated 01/21/2024 showed [AGE] year-old R2 presented to the hospital on 1/21/2024 with a complaint of a fall from the mechanical lift with an injury to the right leg below the knee with pain and side of the head lacerations. X-ray of the right tibia fibula lateral view on the same day showed medial tibial plateau fracture and treated with knee immobilizer 24/7 for three weeks and Neosporin antibiotic cream dressing for scalp after cleaning. Page 1 of 2 145050 145050 06/20/2024 Dupage Care Center 400 N County Farm Rd Wheaton, IL 60187

F 0689 Level of Harm - Actual harm Residents Affected - Few On 06/13/2024 at 2:00 PM, V2 (Director of Nursing) said R2 uses a mechanical lift with two staff members assisting, and he fell from the mechanical lift while V12 (Certified Nursing Assistant-Agency) was transferring R2 from bed to his wheelchair. V2 said V12 should have waited for another staff member to help R2 transfer. V2 said the facility is not using V12 anymore, investigated, educated staff on the mechanical lift transfer, and reported to IDPH. On 06/13/2024 at 2:10 PM, V6 (Certified Nursing Assistant) said he is a regular staff member in that unit and that they should always use two or more staff to transfer residents from the mechanical lift. V6 said R2 is a dependent resident for ADLs, and V12 should have called for help to transfer R2 using the mechanical lift. A facility's policy titled Transfers-EZ Lift/EZ Stand stated, in part, that each resident will be assessed to determine the mode of transfer and the level of staff involved. 145050 Page 2 of 2