145324
09/09/2024
Harmony Park Ridge
1001 North Greenwood Avenue Park Ridge, IL 60068
F 0610
Respond appropriately to all alleged violations.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete a thorough investigation of a resident's bruise of unknown origin and failed to notify the family member of the investigation outcome. These failures apply to one resident (R1) reviewed for injury of unknown origin in the sample of three.
Residents Affected - Few
Findings include: R1 is a [AGE] year-old male originally admitted on [DATE] with medical diagnoses that include and are not limited to, chronic obstructive pulmonary disease, anemia, and atrial fibrillation. According to Minimum Data Set (MDS) dated : 6-27-2024 reads; BIMS (Brief Interview for Mental Status) result of 3/15 indicating a severe cognitive impaired. Section GG reads: maximal assistant of staff for all activities of daily leaving. On 9-7-2024 at 9:20 am R2 (Quality Nursing Director), Presented a reportable incident and said, I was not involved in the investigation. The one that completed the investigation was V1 (Administrator). According to the facility-reported incident dated: 8-5-2024 at 5:00pm reads: R1's family member reported skin alterations to R1's left inner ear and left cheekbone. On 9-7-2024 at 8:00am V12 (R1's Family Member) said, R1 is almost [AGE] year-old, on 8-5-2024 R1 had some bruises to his left ear and left eye after a staff person roughly handled him. V12 said, We called the police, and we had a police report and we told (V1) administrator. V1 told us an investigation would be done but never told us what the investigation findings were, we still waiting. On 9-7-2024 at 12:48 V2 said, I do not see any statements from any nurses or certified nurse assistants in the reportable folder. The facility policy indicates that we need to interview all staff members in contact with R1 on the day of the incident and the shifts prior (72 hours), but we failed to do it, and the investigation was not done according to our policy. On 9-7-2024 at 9:00 pm, V8 (Licensed Practical Nurse) said, I worked on 8-4-2024 during 11-7 shift no one talked/interviewed me on how the shift was. I was never asked to write any statements in regard to R1's bruises. On 9-8-2024 at 12:20 pm (Certified Nurse Assistant) said, I worked on 8-5-2024 on 7-3 and 3-11 with R1, I never talked to the administrator or the director of nursing about R1's bruises, I was never asked/ interviewed. I do not know who they are. On 9-8-2024 at 1:30 pm V14 (Registered Nurse) said, I worked on 8-4-2024 and 8-5-2024 during 11-7 shifts. I was the nurse for R1. No one reported to me any bruises. No one from the facility
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145324
145324
09/09/2024
Harmony Park Ridge
1001 North Greenwood Avenue Park Ridge, IL 60068
F 0610
administration talked to/asked me about R1's bruises, and no one called me from administration.
Level of Harm - Minimal harm or potential for actual harm
9-8-2024 at 1:05 pm V13 (Director of Nursing) said V1 (Administrator) is responsible for completing the investigation. V13 said, I did not participate in the investigation. I expect for us to follow the abuse policy. We need to interview the staff members who worked with residents for the last 72 hours and make sure no other resident is affected. We are responsible for informing the family member of the results of the investigation. I did not talk to the family after the investigation was completed.
Residents Affected - Few
On 9-7-2024 at 11:55 am V1 (Administrator) said, I expect that the staff reports immediately if they see any skin discoloration. I am not sure why they did not report R1's bruises to the left ear and the left eye. Part of the investigation is we need to interview staff members who took care of R1 for 72 hours before the incident. I do not have any documentation that interviews were done. I do not know if R1's family members were contacted to let them know the results of the investigation. I cannot determine the reason of the bruise, but it was unsubstantiated. V1 presented a policy titled: Abuse Investigation and Reporting dated: 11-2023, which reads in part: all reports of resident injuries of unknown source shall be thoroughly investigated. The Administrator or designee will keep the resident and his/her representative informed of the progress of the investigation. The investigator interview associates members (on all shifts) who have had contact with the resident during the period of the alleged incident. Witness reports will be obtained in writing. Either the witness will write his/her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him/her sign and date it. The resident and/or representative will be notified of the outcome immediately upon the conclusion of the investigation.
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