145409
04/03/2025
Michaelsen Health Center
831 North Batavia Avenue Batavia, IL 60510
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 interview and record review, the facility failed to ensure a resident was rolled in a safe manner by two staff persons during incontinence care for 1 of 3 residents (R1) in the sample of 3 reviewed for safety and supervision. This failure resulted in R1 falling out of bed and sustaining fractures of her right and left femurs. The findings include: R1's Face Sheet dated 4/2/25 shows R1 was admitted to the facility on [DATE] with a diagnosis of osteitis deformans of other bones (chronic condition affecting bone structure). R1's MDS dated [DATE] shows R1 requires substantial/maximal assistance to roll left and right (the ability to roll from lying on back to left and right side and return to lying on back on the bed) and with toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement). This same MDS also shows R1 is always incontinent of bowel and bladder. R1's Clinical Notes dated 3/13/25 at 6:58 AM show the following excerpt, While providing incontinence care, CNA stated she turned resident on her side when her legs then dangled off the bed and caused her to slide off the bed. CNA then did her best to lower resident to the floor. On 4/2/25 at 9:10 AM, R1 was lying in bed on an air mattress. R1 said she broke both of her legs a couple weeks ago after she fell out of her bed. R1 said all she knows is that a lady was on one side, and she was on the other side and, I got dropped. R1 said only one person was with her. On 4/2/25 at 2:45 PM, V7, Certified Nursing Assistant (CNA) said she had been changing R1 by herself (on 3/13/25) and as she was rolling R1 in bed, she moved a little too hard, and R1's feet started to slide off the bed. V7 said R1's legs are dead weight and the weight of her body was pulling her off the bed. V7 said R1's legs are so heavy, the (air) mattress is slippery and R1 has no control over her legs, so R1 started to slide out of the bed. V7 said she was unable to get R1's legs back into the bed so she guided her head and shoulders as R1 fell out of her bed. V7 said it all happened so fast she is not sure if R1's knees hit the floor when she fell out of her bed. On 4/2/25 at 9:29 AM, V10, CNA, said before R1 fell, she required two people to change her, one on each side of the bed. On 4/2/25 at 9:39 AM, V9, CNA, said R1 required two people to change her. V9 said for bed baths, one person could wash R1's front side, but then they would need to get a second person to come help turn R1 and wash her back side.
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145409
145409
04/03/2025
Michaelsen Health Center
831 North Batavia Avenue Batavia, IL 60510
F 0689
Level of Harm - Actual harm
On 4/2/25 at 1:20 PM, V5, MDS (Minimum Data Set) Nurse, said she gathers information from the CNAs and the nurses, does observations of residents, and looks at therapy and doctor's notes to determine a resident's mobility and care needs for their MDS. V5 said a resident who needs substantial/maximal assist needs two staff persons to help complete the given activity.
Residents Affected - Few On 4/2/25 at 12:41 PM, V2, Director of Nursing (DON), said a person requiring maximal assist would require two persons to assist with the given activity. On 4/2/25 at 2:22 PM, V6, Registered Nurse (RN), said she was R1's nurse on 3/13/25. V6 said V7 told her she was turning R1 and R1's legs started dangling off the bed and the weight of her legs caused R1 to fall forward, and she slid off the bed. V6 said R1 is heavier and difficult to turn. On 4/2/25 at 2:08 PM, V8, Orthopedic Surgeon, said R1 sustained bilateral femur fractures. V8 said a low energy impact could have caused R1's fractures. V8 said R1 has not been ambulatory for six years and she had poor, weak bone quality. R1's hospital Discharge summary dated [DATE] shows R1 was admitted to the hospital on [DATE]. in part due to bilateral distal femoral fractures due to a fall. R1's H&P dated 3/13/25 shows R1 presented to the hospital after a fall out of bed, she is bedbound at baseline, but apparently rolled out and fell onto both knees. R1's left femur x-ray resulted 3/13/25 shows a transverse fracture of the distal femoral diametaphyseal junction with impaction of three centimeters (cm) and posterior angulation. R1's right femur x-ray resulted 3/13/25 shows a mildly comminuted fracture of the distal diaphysis of the femur with posterior displacement 18 millimeters.
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