Health inspection·May 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 interview and record review, the facility failed to provide safe transfer assistance. This failure resulted in R1 sustaining left and right femoral fractures. This applies to 1 of 3 residents (R1) reviewed for safe transfers. Findings include: R1's Medical diagnosis from the electronic record documents R1 as a [AGE] year old with diagnoses to include a right and left periprosthetic fracture around both artificial knee joints, dementia and physical disability. On 05/02/2024 at 11:18 AM, V13 Hospital staff stated Before these fractures, (R1) could not bear weight, she was contracted and unable to stand up on her own. She was bedbound. On 04/30/2024 at 02:17 PM, V9 Certified Nursing Assistant (CNA) stated That morning I got (R1) up out of bed like I always do. I put my arms under her armpits and did the pivot transfer. I felt her become dead weight then. Her knee seemed like it was swelling. I told the nurse (V6 Licensed Practical Nurse [LPN]). Then I took her down to the shower room and gave her a shower. The other knee was starting to swell up then, so I made sure the nurse knew what was going on. On 04/30/2024 at 11:00 AM V6 LPN stated (R1) is a one person assist for transfer. She's a pivot transfer. We don't always use a gait belt; it seems to cause (R1) pain when we do. We just put our hands under her arm pits and transfer. The Final Report to Illinois Department of Public Health dated 04/22/2024 documents under Summary CNA stated 'When I got to the room to get the resident up to the shower room, the resident was transferred by placing both arms under the patient's armpits to pivot and transfer.' The CNA stated she felt patient dead weight and sat the resident down in wheelchair. The CNA noticed when putting the gown on the resident, there was swelling observed to the left knee and the resident stated that there was pain to the left knee also. Under Summary of the Investigation, it documents All the staff from the day before (04/21/2024) stated they did not notice any swelling to the left or right knee. Xray's bilateral legs were ordered. The results stated there were fractures to both legs. The Radiology Results Report for R1 dated 04/22/2024 at 01:00 and 01:13 PM document under Findings: Right knee- There is an acute versus subacute comminuted fracture of the distal femur, immediately proximal to the distal femoral prosthesis with angulation. Left knee- There is an acute distal femoral shaft fracture, located immediately adjacent to the prosthetic femoral component of total knee Page 1 of 2 145657 145657 05/04/2024 The Pearl of Downers Grove 3450 Saratoga Avenue Downers Grove, IL 60515

F 0689 replacement, which remains in anatomic alignment. Level of Harm - Actual harm The care plan for R1 dated 09/02/2023 and reviewed 03/05/2024 documents Transfer : The resident requires (SPECIFY what assistance) by (X) staff to move between surfaces (SPECIFY FREQ) and as necessary. Date Initiated: 09/02/2023 Revision on: 10/07/2023; which was incomplete and did not specify R1's individualized transfer needs. Residents Affected - Few On 05/02/2024 at 10:45 AM, V2 Director of Nursing stated Transfer status is determined by the physical therapist. We monitor the residents everyday. The staff will notify nursing if a resident has a change in ability so the resident's transfer status can be reassessed. That information is then used in the care plans. The care plan for (R1) isn't updated. That is why there is no direction for transfers. On 05/01/2024 at 02:30 PM, V5 Physical Therapist stated The gait belt should always be used for every transfer. Anything else is not a safe transfer. On 05/01/2024 at 11:25 AM, V4 Medical Director stated (R1) has a lot of medical issues and has declined recently. She is very contracted on both legs. The injury may be the result of a forceful transfer. The undated Activities of Daily Living policy documents under Mobility (transfer and ambulation, including walking) i. Residents will be assisted with transfer and mobility as ordered by the physician/practitioner and/or as instructed in the resident's care plan 145657 Page 2 of 2