Health inspection·December 4, 2024

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 a gait belt during ambulation, for one resident (R2) of three residents, in a total sample of three residents reviewed for supervision. This failure resulted in R2 being hospitalized , with a femur fracture which required surgical intervention. Findings Include: Facility Policy, entitled Gait Belts, dated 4/13, document, Gait belts are used to help prevent injury of staff or residents during transfers and ambulation; 1. Gait belts should be used by all staff when ambulating or transferring a resident with an unsteady gait. R2's Electronic Medical Record/EMR document R2's diagnosis to include: Displaced supracondylar fracture with intracondylar extension of lower end of left femur, Muscle wasting and atrophy, Muscle Weakness, Chronic obstructive pulmonary disease, Heart Disease, Hypertension, Peripheral vascular disease, Displaced fracture of proximal phalanx of left lesser toe, Displaced fracture of proximal phalanx of right little finger, Legal blindness, and osteoporosis. R2's Quarterly, Minimum Data Set, dated [DATE] [seven days before R2's fall], document: Section GG The resident is dependent-helper does all of the effort. Resident does none of the effort to complete the activity [For transfers] chair/bed to chair transfer, toilet, transfer, and tub/shower transfer. [And the resident is a] partial/moderate assist to walk 10 feet and to walk 50 feet with two turns. Positioning sit to lying, lying to sitting on the side of the bed, and sit to stand, resident requires substantial/maximal assistance-helper does more than half the effort. R2's progress notes document: 10/29/24 3:35 p.m., Called to resident room. Resident noted to be sitting on floor left leg turned inward from hip to knee, Resident complaining of pain. Right ankle turned inward. Complaining of pain, no pulse noted. Aide to back of resident sitting behind her. States resident went to pivot and tried to sit too soon and fell to floor. Called for assistance. VS [Vital Signs] obtained. Called 911. POA [Power of Attorney] called. Resident to be transported to [hospital] for eval[uation]; 10/29/24 3:50 p.m., Ambulance left with resident to transport to [hospital]; 10/29/24 7:07 p.m., [hospital] called, and states resident is being flown out to [another hospital] for multiple fractures; 10/30/24 11:25 a.m., This nurse called [hospital] and had her x-ray reports faxed to the facility. X-ray reports resulted in resident having a left acute, comminuted fracture of the distal femur with intra-articular extension in the knee, and a right interval splining of the comminuted fractures of the distal tibia and fibula diaphysis; 11/4/24 4:16 p.m., [R2], an [AGE] year old female, was readmitted from hospital after her recent hospitalization for orthopedic surgery. During the resident's hospitalization, [R2] has experienced a decline in her ability to function. Page 1 of 2 145488 145488 12/04/2024 Rushville Nursing & Rehab Ctr 135 South Morgan Street Rushville, IL 62681

F 0689 R2's x-ray result, dated 10/29/24, document findings as commuted, displaced distal, femoral shaft/metaphysis fracture. Level of Harm - Actual harm Residents Affected - Few R2's hospital surgical report, dated 10/30/24, document the procedure performed was open reduction, internal fixation, left supracondylar distal femur fracture with intracondylar extension; and intramedullary fixation of a right tibial shaft fracture. On 11/26/24, at 11:55 a.m. V2/Director of Nursing confirmed a gait belt was not used while V4/Certified Nursing Assistant was ambulating R2 at the time of R2's fall. On 11/26/24, at 12:40 p.m., V5/Director of Rehabilitation confirmed R2 is blind and can only see shadows; ambulates with a front-wheeled walker; Requires one assist during ambulation; a gait belt was used during therapy and Everyone should have a gait belt used unless they are independent. On 11/26/24, at 12:50 p.m., V3/Assistant Director of Nursing confirmed R2 was not wearing a gait belt at the time of her fall; R2 is blind; R2 has a fear of falling; and R2 needs assistance ambulating. On 11/26/24, at 1:30 p.m., R2 confirmed not wearing a gait belt when she fell and fractured her leg. On 12/4/24, at 11:40 a.m., V1/Administrator confirmed, prior to R2 falling, R2 required one assist with a gait belt and walker. V1 also confirmed V4 was terminated for not following the facility Gait Belt Policy as V4 did not use a gait belt when assisting R2. On 12/4/24, at 12:07 p.m., V5 confirmed, prior to R2's fall, R2 required one assist, a gait belt, and a walker, for ambulation. On 12/4/24, at 12:25 p.m., and 12:35 p.m., V9/Certified Nursing Assistant and V10/Certified Nursing Assistant confirmed R2 required one assist/gait belt/walker when up ambulating. 145488 Page 2 of 2