Health inspection·December 3, 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 interview and record review, the facility failed to implement effective interventions to monitor a resident at high risk for falls. This failure affected one (R1) of three residents reviewed for falls and resulted in R1 sustaining a fall while in front of the nursing station for supervision, that resulted in emergent hospital transfer for treatment of a closed nondisplaced fracture of the acromial end of the left clavicle. Findings include: R1 is an [AGE] year-old female admitted to the facility on [DATE] with the diagnosis history of Congestive heart failure, hypoxemia, chronic obstructive pulmonary disease, dementia, cataract, gastric esophageal reflex disease, hyperlipidemia, and aphasia after cerebral infarct. On 10/15/2024 record review documents that R1 fell in front of the nursing station requiring R1 to go to the emergency room for further evaluation. Hospital records reviewed document that R1 had a closed nondisplaced fracture of the acromial end of the left clavicle and R1 was admitted to the hospital. On the (MDS) Minimal data Set assessment of 09/03/2024 section C the BIMS (Brief Interviewed Mental Status) score was 01/15 (severe cognitive impairment). On MDS of 09/03/2024 GG section R1 requires supervision/touching assistance with manual wheelchair mobility on 50 feet distance. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. On 12/02/2024 at 11:02AM interviewed R1 who was not able to answer questions, but only repeat the last words of each question such as pain for the question; Do you have pain? Did you have a fall? R1 answered fall. On 12/02/2024 at 11:25 AM V6 (Certified Nursing Assistant) said, R1 was assisted with her toileting needs after breakfast and brought to the nursing station for V5 (Registered Nurse) to monitor because R1 is a high fall risk. During the fall, V6 stated that she was in a room providing care to another resident. R1 can get anxious and not able to follow cues and redirections depending how R1's day is going. On 12/02/2024 at 12:44 AM V5 (Registered Nurse) said that she was standing at least 100 feet away Page 1 of 2 145557 145557 12/03/2024 Alden Estates of Barrington 1420 South Barrington Road Barrington, IL 60010

F 0689 Level of Harm - Actual harm Residents Affected - Few from R1 by her medication cart when R1 started to self-propel on her wheelchair and started to lean to the right side and slid out of the wheelchair. V5 said, R1 was too far and fell before she got to R1. R1 is alert to person has dementia and requires maximum assistance with her activities of daily living. R1 may follow direction or cues depending how her day is going and if R1 slept at night. Usually there are 3-4 residents in front of the nursing station for nursing to monitor closely to prevent falls and the day of R1's fall, V5 was the only person close to nursing station by the rooms in the 100's wing. V5 said that it is hard and almost impossible to monitor 3-4 residents at the nursing station and provide care to other residents. On 12/02/2024 at 1:35PM V4 (Restorative Aide) said that R1 is under restorative program and needs to be provided cues and to hear let's walk a couple of times before R1 can follow commands. R1 sometimes will not follow cues. R1 uses wheelchair under supervision/touching assistance in the unit. On 12/02/2024 at 1:30PM V3 (Restorative Nurse) said that R1 uses a wheelchair and requires supervision/touching assistance and nurses and nursing assistance will communicate on report on how much assistance each resident requires. R1 has dementia and will not follow cues at times. V3 was unable to say how much close supervision and touching assistance R1 requires. On 12/02/2024 at 3:03PM V2 (Director of Nursing) said, R1 has dementia and usually is responsive to name only but can follow cues at times and self-propel on her wheelchair under supervision/touching assistance. V2 was asked if a distance of 100 feet is acceptable for supervision of R1 while at the nursing station and V2 did not answer. V2 said, I do not expect nurses to provide one to one supervision. V5 (Registered Nurse) was close to the nursing station on her medication cart and unable stop the fall. Upon review of R1's medical record, it was noted that there is no wheelchair mobility and/or locomotion care plan to communicate to the interdisciplinary team how to safely provide care to R1 while using wheelchair, taking into account R1's cognitive impairment. On 12/02/2024 at 1:00PM V1 (Administrator) presented facility Policy Titled, Management of Falls (dated 08/2020), which reads: Policy: The facility will assess hazards and risks, develop a plan of care to address hazards and risks, implement appropriate resident interventions, and revise the resident's plan of care to minimize the risks for fall incidents. 145557 Page 2 of 2