Health inspection·April 20, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to notify R1's physician and representative on 4/9/23 when R1 was found on the floor. On 4/14/23 R1 was diagnosed with comminuted fractures to her right tibia and fibula. This applies to 1 of 3 residents (R1) reviewed for injury of unknown origin. Findings include: R1 is a non-verbal, non-ambulatory, [AGE] year-old female admitted to the facility on [DATE] with diagnoses including heart failure, hypertension, peripheral vascular disease, profound intellectual disability, and other specified disorders of bone density and structure. On 4/14/23 R1 was diagnosed with comminuted fractures to her right tibia and fibula. 1. 4/9/23 On 4/19/23 at 5:27pm V1 (Administrator), on 4/19/23 at 4:46pm V2 (Director of Nursing), on 4/18/23 at 2:26pm V9 (Nurse), on 4/19/23 at 3:25pm V17 (Nurse), on 4/19/23 at 1:35pm V14 (Receptionist), and on 4/19/23 at 4:27pm V22 (Certified Nurse Assistant/CNA) said that on 4/9/23, R1 was found on the dining room floor after the facility's Easter Egg hunt. On 4/18/23 at 2:26pm V9 (Nurse) said that she did not report R1 being found on the floor to R1's Doctor or Nurse Practitioner. 2. 4/12/23 On 4/19/23 at 4:03 PM, V21 (CNA) said that on 4/12/23, while changing R1's adult brief, R1's right leg buckled, but she did not report the incident to anyone. 3. 4/13/23 On 4/18/23 at 12:52pm, V8 (CNA) said that on 4/13/23 she observed swelling and a bruise to R1's right ankle and she reported it to V9 (Nurse). On 4/18/23 at 2:26pm, V9 said that on 4/13/23 she observed a bruise and swelling to R1's right ankle around 6am but did not notify R1's doctor or document it. 4. 4/14/23 On 4/18/23 at 12:32pm, V7 (Nurse) said that on 4/14/23 she was informed by V8 (CNA) that R1 had swelling and a bruise to her right ankle. V7 (Nurse), said that she observed the swelling and bruise to R1's right ankle and notified V6 (Wound Nurse). On 4/18/23 at 12:15pm, V6 said that on 4/14/23 she Page 1 of 2 145536 145536 04/20/2023 Citadel of Bourbonnais,the 20 Briarcliff Lane Bourbonnais, IL 60914

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was notified of a bruise and swelling to R1's right ankle by V7 and she notified V18 NP (Nurse Practitioner). On 4/19/23 at 3:05pm, V18 said that on 4/14/23 she was informed of bruising and swelling to R1's right ankle and gave orders for x-rays and to be sent to the hospital for evaluation. V18 said that she was never notified on 4/9/23 when R1 was found on the floor, on 4/12/23 when R1's right knee buckled or on 4/13/23 when R1's right ankle was observed with a bruise and swollen. V18 said she would have given at minimum orders for observation. On 4/19/23 at 3:55pm V20 (R1's Primary Care Physician) said he was not notified on 4/9/23 when R1 was found on the floor, on 4/12/23 when R1's right knee buckled or on 4/13/23 when R1's right ankle was observed with a bruise and swollen. On 4/18/23 V12 (R1's Orthopedic Doctor) said that R1's fracture was the result of a onetime acute injury resulting in a fracture. V12 said the injury was the result of trauma to R1. A review of R1's electronic record did not show any documentation for 4/12/23 or 4/13/23 regarding any buckling, bruising, or swelling to R1's right leg or right knee. R1's nursing progress note showed that on 4/17/23 at 9:51am, V9 made a late entry, showing that on 4/9/23 R1 was found on the floor in the dining room at 3:15pm. No progress notes showed any notifications were made to R1's doctor or guardian regarding R1 being found on the floor on 4/9/23. R1's 4/14/23 at 1:45pm progress note showed that V6 (Wound Nurse) noted bruising to right ankle, assessment noted with swelling, no expression of pain with palpitation, spoke with NP (Nurse Practitioner), received stat X-ray orders. R1's 4/14/23 10:55am Lab/Radiology progress note showed, 4/14/23 R- ankle reviewed by V18 (NP). New orders to send to emergency department. R1's 4/14/23 hospital records showed that R1's x-rays showed comminuted fractures to R1's right tibia and fibula. R1's 4/18/23 orthopedic office visit documentation showed R1's date of injury 4/9/23. The documentation showed a diagnosis of comminuted distal fractures of the right tibia and fibula. V14's (CNA) 4/15/23 statement showed that on 4/9/23, V14 saw R1 on the dining room floor. V9's (Nurse) 4/15/23 statement showed that on 4/9/23 V9 saw R1 on the dining room floor. V22's (CNA) 4/15/23 statement showed that on 4/9/23 she saw R1 on the dining room floor. V21's (CNA) 4/14/23 statement showed that on 4/12/23 R1's knee buckled. V8's (CNA) 4/14/23 Witness Statement showed, V8 noticed on Thursday (4/13/23) swelling to R1's right leg and reported to the nurse. The facility's Assessing Falls and Their Cause policy dated March 2018 showed, steps after a fall notify residents attending physician and family in an appropriate time frame and complete an incident report for resident files no later than 24 hours after file occurs. The incident report form should be completed by the Nursing Supervisor on duty at the time and submitted to the Director of Nursing Services. The policy showed under Reporting, the facility is to report the incident to the Attending Physician, the family, the Director of Nursing and Nursing Supervisor on duty. The facility's Incident Reporting policy dated December 2017 showed, as required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents. Our facility will report the following events to appropriate agencies, serious injuries related to fall confirmed by a diagnosis e.g., fracture, hematoma Incidents shall be reported via fax or e-mail to appropriate agencies as required by current law within 24 hours of such incident, a written report detailing the incident in action taken by the facility after the event shall be sent and delivered to the state agency within 48 hours of reporting the event or as required by federal state law. 145536 Page 2 of 2