Health inspection·July 5, 2023

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. Based on observation, interview and record review, the facility failed to control a resident in a wheelchair during a transportation and prevent injury and failed to report a resident injury to the nurse for one resident (R1) out of three residents reviewed for accidents in a sample of three. Findings include: The facility's Notification for Change In Resident Condition or Status policy revised 12/7/17 documents The facility and/or facility staff shall promptly notify appropriate individuals of changes in the resident's medical/mental condition and/or status. 2. The nurse supervisor/charge nurse will notify the DON (Director of Nursing), physician and unless otherwise instructed by the resident the resident's next of kin or representative when the resident has any of the afore mentioned situations or: A. the resident is involved in any accident or incident that results in an injury including injuries of an unknown source. The facility's Transportation Driver job summary undated documents Responsibilities: e. Transports resident to and from scheduled appointment and approved locations in a safe and responsible manner. h. Responsible for the care and well-being of all residents. R1's minimum data set (MDS) documents a brief interview for mental status (BIMS) score of 15. A BIMS score of 12-15 indicates a resident is cognitively intact. R1's MDS also documents R1's locomotion off the unit requires a one person physical assist. On 7/5/23 at 8:25 AM, R1 observed sitting in her bed with bilateral bruising to her face, bloodshot right eye, bruising to the left arm, skin tear to her right first knuckle and a skin tear to her left forearm. R1 stated All this (point to her arm, facial bruising and skin tears to her right hand knuckle and left forearm) happened while I was getting in the van for dialysis on Saturday (7/1/23). I was going out the front door and all the sudden I started rolling downhill because the driver didn't have a hold of my wheelchair. They always hold my wheelchair when I come out of the facility because of that slope in the walkway. I started rolling and I couldn't stop myself. I wound up rolling downhill and slammed into the van's lift. The nurse never came out and looked at anything before I went to dialysis. On 7/5/23 at 9:00 AM, V3, Van Driver (VD), stated I pulled open the front door and (R1) started pushing herself through the doors with their feet. I didn't grab her wheelchair because she was wheeling herself toward the van. It looked like she lost control of the wheelchair and started rolling toward the van. She put her hands up in the air trying to brace herself for impact when she hit the lift. I didn't see her hit her head. When I looked at her, she had a cut on her right hand. I grabbed Page 1 of 2 145266 145266 07/05/2023 Fondulac Rehabilitation and Health Care Center 901 Illini Drive East Peoria, IL 61611

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the emergency kit out of the van looking for a Band-Aid, but I couldn't find one. So I grabbed a rag and wiped the blood off her hand. I then loaded her up in the van and took her to dialysis. When I got her to dialysis, I told the technician and he put a Band-Aid on her hand. I don't know why I didn't tell the nurse before loading her up in the van and taking her to dialysis. On 7/5/23 at 9:13 AM, V2, DON, verified there is a downhill grade to the walkway outside the facility entrance and stated When going out the front entrance of the facility, the staff should have control of the resident's wheelchair for safety. (V3, VD) should have immediately reported the incident and gotten a nurse to assess (R1) prior to loading her in the van. She shouldn't have loaded her up without a nurse looking at her. I was called by the dialysis unit and informed of the injuries so I requested she be sent to the hospital for evaluation. (R1) wasn't assessed by us until she got back from the hospital. When I saw all the bruising on her face, I was surprised when the hospital said she didn't have any fractures. She only has the bruising to her face, left arm and the skin tears to her left arm and hand. She also had a right black eye when she came back from the hospital. On 7/5/23 at 11:21 AM, V4, VD, stated When I take (R1) to dialysis, I always hold onto her wheelchair when we go out the front door because of that slope. I don't want her rolling out into the parking lot. Last week we started using the side door because it's flat. 145266 Page 2 of 2