145220
11/14/2024
Pine Crest Health Care
3300 West 175th Street Hazel Crest, IL 60429
F 0689
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
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** Based on interviews and record reviews the facility failed to follow their policy and procedure for mechanical lift transfers by not ensuring two staff were present while attempting to transfer a resident using the mechanical lift. This failure applied to one (R1) of three residents reviewed for accidents/hazards.
Findings include: R2 is a [AGE] year-old male with a diagnoses history of COPD, Dysphagia, Partial Paralysis Following a Stroke, Morbid Obesity, Other Seizures, Weakness, Anxiety Disorder, and Mild Recurrent Major Depressive Disorder who was admitted to the facility 05/06/2022. On 11/12/2024 at 2:04 PM Observed R2 in his room sitting in his wheelchair showing no signs of injury or distress. R2 stated a while ago he had a fall while being transferred from his bed to his chair by a certified nursing assistant with the mechanical lift. R2 stated the certified nursing assistant lost her balance and the mechanical lift fell on his leg. R2 stated he did experience some pain. R2's Current Care Plan documents he is risk for falls as evidenced by use of a wheelchair, poor sit to stand balance, left side weakness, gait/balance problems, and use of mechanical lift with interventions implemented 05/11/2023 including two person transfer when using a Mechanical Lift with a Carrier Sling per the facility's Policy and Procedure and manufacture guidelines; and intervention implemented 10/02/2024 of staff education on proper and safe use of mechanical lift during transfers. R2's progress note created by V5 (Licensed Practical Nurse) dated 10/2/2024 documents writer was called to room by CNA (Certified Nursing Assistant), writer noted resident on floor on right side with carrier sling still attached. Resident stated he fell on his right side, and he scraped his elbow. Writer noted two small abrasion and small hematoma to the right elbow. Resident lifted to bed and sent to the veterans hospital emergency room for evaluation. R2's Fall Risk Management Report dated 10/02/2024 documents V5 (Registered Nurse) was called to R2's room by CNA (Certified Nursing Assistant), R2 experienced a fall, and was found on the floor on his right side with the carrier sling still attached. On 11/13/2024 at 2:18 PM V5 (Registered Nurse) stated on 10/02/2024 when R2 fell V10 (Certified Nursing Assistant) was the only staff attempting to transfer him using the mechanical lift. V5 stated she asked V10 what happened, and she reported the mechanical lift tipped over while she was transferring R2 out of bed. V5 stated R2 sustained a small abrasion to his elbow as a result of the incident and he was sent to the hospital because he was on blood thinners.
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145220
145220
11/14/2024
Pine Crest Health Care
3300 West 175th Street Hazel Crest, IL 60429
F 0689
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
On 11/13/2024 at 3:21 PM V3 (Director of Nursing) stated V10 (Certified Nursing Assistant) was suspended for three days for failure to provide a proper transfer using a mechanical lift by not having a second staff with her when transferring R2 on 10/02/2024 when he fell. Corrective Action report dated 10/02/2024 documents V10 (Certified Nursing Assistant) was suspended for performing duties in an unsafe manner by attempting to transfer R2 using a mechanical lift without waiting for staff assistance causing R2 to fall, sustain an injury and be transferred to the hospital for evaluation and includes V10's signature dated 10/03/2024. The facility's Limited Lifting Resident Handling policy received 11/14/2024 states: In order to protect the safety and well-being of the staff and residents, and promote quality care, this facility will use Mechanical Lifting devices for the lifting and movement of residents. Mechanical lifting devices shall be used for any resident needing a two person assist. The transferring needs of residents will be assessed on an ongoing basis and designated into one of the following categories: 2 = 2 person transfer (Only when use of Sit to Stand Lift is not possible).
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