145536
12/29/2023
Citadel of Bourbonnais,the
20 Briarcliff Lane Bourbonnais, IL 60914
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
Based on observation, interview, and record review, the facility failed to transfer a resident safely from a shower chair. This failure resulted in R1 sustaining a left tibial fracture after a fall in the shower room. This applies to 1 of 3 residents (R1) reviewed for falls in a sample of 3. The findings include: R1's Face sheet shows diagnoses of diabetes with diabetic neuropathy, cerebral infarction, repeated falls, muscle weakness, and lack of coordination. R1's MDS (Minimum Data Set) dated 7/20/23 shows her cognition is intact. On 12/28/23 at 9:52 AM an observation was made of the main shower room where R1's fall occurred. There are 3 shower stalls on the right-side wall, and 1 shower stall on the left wall. The last/furthest shower stall on the right side has an approximately 4-foot-long horizontal grab bar, which is about 6 inches to the left of the shower, above the tile floor. On 12/27/23 at 11:15 AM, R1 said at the time of her 9/14/23 fall, there was a towel on the floor, and she told V7 (CNA/Certified Nurse Assistant) that she thought she was going to fall if she tried to stand up. R1 said the next thing she knew, she had fallen and landed on her butt with her legs out in front of her. R1 said she thinks she fell because the towel under her feet slipped out and her feet slipped too. On 12/28/23 at 9:36 AM, R1 said the fall took place in the main shower room, outside of the last/furthest shower on the right-hand side while she attempted to stand up using the grab bar outside of the shower stall. On 12/28/23 at 1:57 PM, R1 said at the time of her fall she had bare feet and was not wearing any non-skid socks or slippers. R1 said she did not fall because of her knee buckling or her hand slipping off the grab bar, she fell immediately and was never able to stand upright. On 12/28/23 at 10:25 AM, V7 (CNA) said she put a towel down on the floor before attempting to help R1 stand up. V7 said she was watching R1's hands on the bar when she fell and did not notice what happened with her feet. On 12/28/23 at 11:28 AM, V7 said R1 was not wearing non-skid socks or slippers at the time of her fall. V7 said R1 had bare feet, and a gait belt was not used. R1's nurse's note dated 9/14/23 at 21:55 (9:55 PM) shows that at 2100 (9 PM), resident was observed in shower room laying on her right side and complaining of pain to her left leg. When the nurse asked the resident what happened, R1 said, as she was beginning to stand holding the bar in shower room, her foot slipped, and she fell down. The CNA was unable to prevent the fall and placed a dry towel on the floor, but R1 still slipped. R1's hospital record documents left lower leg x-ray completed on 9/15/23 at 8:25 AM had finding of comminuted oblique fracture mid tibial diaphysis.
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145536
145536
12/29/2023
Citadel of Bourbonnais,the
20 Briarcliff Lane Bourbonnais, IL 60914
F 0689
Level of Harm - Actual harm
Residents Affected - Few
On 12/27/23 at 2:03 PM, V5 (CNA), said when she gives a resident a shower in the shower room, she will dry the floor with towels and then remove all towels before the resident stands up. V5 said, I always remove the towels because I don't want the resident to slip, especially because they don't have any shoes on and are barefoot. I was trained to wipe the floor up and remove the towels before having the resident stand up. On 12/27/23 at 2:24 PM, V6 (CNA) said before transferring a just-showered resident from the shower chair into their wheelchair, I secure the area. I make sure the floor is dry and transfer her with gait belt and lift from shower chair to her wheelchair. I dry the floor and remove all of the towels, I don't leave a dry towel down for the resident to stand on. That would be a safety issue, the resident could slip on the towel. R1's Care Plan dated 11/8/23 shows R1 has a risk for falls related to weakness. Interventions include ensure R1 is wearing appropriate footwear (slip resistant socks and/or shoes) when ambulating or mobilizing in wheelchair and R1 needs a safe environment free of clutter. This same Care Plan shows R1 has had previous falls on 12/31/22, 3/26/23, 8/11/23, and 9/14/23. The 9/14/23 fall states, Resident was standing up from the shower chair when her foot slipped, and she fell. She sustained a left tibia fracture. R1's final incident report dated 9/22/23 at 10:00 AM shows that on 9/14/23 resident was observed on the floor lying on her right side. When asked what happened, resident stated as she was beginning to stand holding onto the bar, her foot slipped, and she fell. NP notified and resident sent out to ER. Report of a closed fracture to left tibia received and resident returned to the facility after left tibial nailing surgery.
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