Health inspection·May 2, 2023

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Few Based on record review and interview, the facility failed to ensure a 2-person assist when providing bathing and bed mobility and preventing fall for one of 4 residents (R2) reviewed for accidents and supervision. This failure resulted in R2's fall and was transferred to a local hospital after sustaining multiple skin tears to left upper arm, left lower leg and right neck, ecchymosis on the right neck, left hand and forearm. Findings include: R2's Minimum Data Set, (MDS), dated [DATE] documents R2's cognitive skills for daily decision making is moderately impaired. R2 requires extensive assistance 2-person assist in bed mobility, transferring and bathing. No fall history documented. R2's Physician Order Sheet, (POS), dated 3/6/23-3/17/23 documents pertinent diagnoses as Age-related cognitive decline, Unsteadiness on feet, Difficulty in walking, not elsewhere classified and History of falling. R2's Care Plan dated 10/27/22 documents, R2 is at risk for falls related to glaucoma. Personal history of falls, Diabetes Mellitus, and weakness. 3/17/2023-witnessed fall out of bed with injury Interventions: 3/17/2023 documents R2 was sent to ER for evaluation; Observe for safety; Invite/escort to activities of choice as tolerated as desired; Rest periods as needed; Cues/redirect as needed, use proper assistive device wheelchair/walker as needed; Proper footwear as indicated; Clutter free environment; Call light within reach while in room and remind resident to call for assistance as needed. R2's Fall Risk assessment dated [DATE], documents R2 is High Risk for Falls. R2's Fall Investigation dated 3/17/23 documents, while CNA was attempting to change resident, she reached over to grab the (Brand) incontinence underwear, and the resident, continued to roll out of the bed. The resident hit her head on the dresser next to bed. R2's face, arm, and leg have skin tears. Bruising and pain noted. R2's medical records, dated 3/17/23, documents that R2 presented to a local hospital after a fall Page 1 of 2 145601 145601 05/02/2023 Aviston Countryside Manor 450 West 1st Street Aviston, IL 62216

F 0689 Level of Harm - Actual harm Residents Affected - Few from bed unwitnessed at nursing home. Patient found on floor by staff wedged between bed and wall, Unknown if there was a loss of consciousness, (LOC). Has multiple skin tears: Left upper arm, left lower leg and right neck, has ecchymosis right neck, left hand and forearm. Patient is poor historian and oriented x 1. Brought to ER by EMS who provided history. All vital signs within normal limits except blood pressure which was 199/111 at 7:10 AM, at 8:00 BP was 157/65. Physical exam revealed- Mucous: Extremity Left Upper Extremity, ([NAME]), with flexion deformity elbow, Contracture left fingers, multiple areas of chamois left elbow/forearm/hand with soft tissue swelling, (sts), neurovascular intact. No pelvic tenderness to palpitation, (ttp), or instability. Hips partially flexed and knees flexed. Unable to fully extend. No leg length discrepancy noted. NF intact lower extremities. Large skin tear distal upper arm and partially avulsed, (torn flap of skin). Left lower extremity, (LLE), with anterior skin tear with partially avulsed skin. 5 x 5 cm skin tear with avulsed skin right lateral neck with surrounding ecchymosis, no hematoma appreciated. Neurological: Oriented x1, repeated What are you doing to me? Speech is clear and fluent. Does not initiate conversation. Does not answer questions. Able to move extremities although has limit contractions. Psychiatric: Patient is uncomfortable and aggravated with any questions or examinations. She was upset while cleaning wounds and changing positions. 3/17/23 X-ray, (XR), elbow Left, (LT), Exam XR hand LT, XR elbow LT, XR humerus LT Min, XR forearm LT, CT Head without Contrast and XR Chest documents some arthritic, ground glass opacity in the right upper lobe, and degenerative disease but there were no fractures or intracranial hemorrhage, midline shift or mass present. There was fecal impaction. Summary: Discussed findings with POA, her daughter. She declines cervical collar and spine surgery follow-up for her mother. She states that her mother would not tolerate it and it would make her uncomfortable. She instead wants comfort care and would contact hospice. R2 was returned to nursing home. V18 (Certified Nursing Assistant/CNA), stated she was reaching for a diaper when R2 fell out of bed. It was just a fluke, because R2 normally does not move without assistance or physical guidance. R2 is a 2-person assist, but to change her in bed can be accomplished by 1 person. The Facility policy Fall Management dated July 2017 documents it is the facility's policy to assess and manage resident falls through prevention, investigation, and implementation and evaluation of interventions. 145601 Page 2 of 2