145400
03/26/2024
Westminster Village
2025 East Lincoln Street Bloomington, IL 61701
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 observation, interview, and record review the facility failed to utilize the safest assistive devices for one resident (R1) of three residents reviewed for falls in a sample list of three residents. This failure resulted in (R1) slipping from a sit to stand lift and sustaining a dislocated shoulder requiring closed reduction.
Findings Include: 1. R1's Care Plan updated 3/5/24 includes the following diagnoses: Fall, Chronic kidney Disease Type III, Congestive Heart Failure, Muscle Weakness, Difficulty Walking, Unsteadiness on Feet, Abnormal Gait, Lack of Coordination, and Abnormal Postures. This Care Plan documents R1 is High Risk for Falls. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is moderately cognitively impaired, has functional limitations to all four extremities, uses a manual wheelchair and is totally dependent to roll wheelchair 150 Feet. This MDS also documents R1 is dependent for Sit to Stand, Toilet Transfer, and Toilet hygiene. R1's Care Profile Audit Report printed 3/26/24 documents: On 2/21/24 at 11:26AM Sit-to-Stand (lift). On 2/21/24 at 2:43PM (Sling type mechanical lift). On 2/27/24 at 7:36AM (Sling type mechanical lift). R1's Physical Therapy Note dated 3/10/24 by V12, Physical Therapy Assistant (PTA) documents Precautions/Contraindications: Fall risk, Lower extremity Edema, Low Activity tolerance, (sling type Mechanical Lift) transfer, Left Lower Extremity Numbness, Limited bilateral shoulder flexion, Bilateral Hand and Wrist Edema, and Left Quadriceps Weakness. R1's Incident Note dated 03/11/2024 at 12:39PM by V6, Registered Nurse (RN) documents (R1) assisted to toilet with Sit to stand lift, two CNAs used sit to stand trial to clean (R1) when (R1) slid out of sling and was lowered by CNA to floor. Range of Motion Within Normal Limits, (R1) complains of pain in Right upper arm. (R1) assisted by three staff and (sling type mechanical lift) to bed. (R1) complains of increasing pain in Right shoulder and inability to move. Grip equal and pulses even bilaterally. Power of Attorney present and requesting (R1) to be seen. Ambulance called and R1 sent to emergency room at approximately 11:45AM. R1's emergency room report from 3/11/24 at 4:11PM documents reports to Emergency Department status
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145400
145400
03/26/2024
Westminster Village
2025 East Lincoln Street Bloomington, IL 61701
F 0689
post fall with obvious right shoulder deformity.
Level of Harm - Actual harm
R1's X-ray dated 3/11/24 at 1:45PM documents Comparison to 2/12/24 (Chest X-Ray) Impression: Right Glenohumeral Shoulder Dislocation. Further notes by emergency room staff document R1 required closed reduction for shoulder dislocation.
Residents Affected - Few
On 3/26/24 at 2:00PM V6, RN stated I was (R1's) nurse the day (R1) slid out of the sit-to-stand. I hadn't worked that hall for a while and I thought (R1) was using a sit to stand so I told the CNAs they could use the sit-to-stand to clean (R1) after a bowel movement. (V8 and V9) Certified Nurse's Aides (CNAs) transferred (R1) from the chair to the toilet using a (sling type mechanical lift). (R1) had a bowel movement and so they could clean (R1), the CNA's used a sit to stand lift. They reported to me that when they stood (R1), (R1) was weak and began to slip so they eased (R1) to the floor. (R1) was in between the toilet and the door on the floor when I got to the room. (R1) was moaning a little and said her right shoulder hurt. We got the (sling type mechanical lift) and put (R1) in bed. I didn't see any redness or swelling. I put ice on the shoulder and elevated (R1's) right arm on a pillow. R1's power of attorney was here and requested we send (R1) to the hospital. I notified (V3, Assistant Director of Nursing) and we sent (R1) to the hospital. On 3/26/24 at 2:30PM V8, Certified Nurse's Aide (CNA) stated I was with (R1) when (R1) fell (3/11/24). We moved (R1) to the toilet with a (sling type mechanical lift). We thought we could clean (R1) easier with the (sit to stand lift) so we stood (R1) up from the toilet with the sit-to-stand lift. (R1) was too weak and slipped out of the sit to stand sling. (V9) Certified Nurse's Aide and I assisted (R1) to the floor. Once we had (R1) on the floor (R1) was moaning in pain and I thought (R1's) shoulder looked a little crooked. (V6) came in and the three of us got (R1) in the (Sling type mechanical lift) and took (R1) back to bed so (V6) could look at (R1). (R1's) family member was here and asked (R1) be sent to the hospital and that is what we did. On 3/26/24 at 3:00PM V4, Occupational Therapist, Director of Therapy verified the Physical Therapy noted 3/10/24 documents (R1) required a (sling type mechanical lift) for transfer. On 3/26/24 at 4:00PM V10, Nurse Practitioner, stated I wasn't there so I couldn't say for certain the fall from the lift caused (R1's) shoulder dislocation, but (R1) was a larger person and slipping out of a lift, would have put pressure on (R1's) shoulders.
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