Health inspection·January 31, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview and record review, the facility failed to ensure its staff follow safety precautions to prevent hand injury and failed to provide timely medical care for one resident (R1) reviewed for injury in a sample of three. These failures resulted in R1 sustaining pain and swelling in his right hand and being transported to the Emergency Department/ED. Findings include: R1's Radiology Results Report, Reported 1/11/24, documents: Impression: 1. Suspicious for volar dislocation of the middle phalanx at the right long finger PIP/proximal interphalangeal joint. R1's Hospital Notes dated 1/11/24 documents: R1 was evaluated and treated in our Emergency Department on 1/11/24. X-ray Impression: No acute osseous abnormality. After Visit summary: No acute abnormalities seen on imaging. Recommend stabilization and symptom management. The Facility's Report Form-(State Department) Notification for R1, dated 1/10/24, documents: Statement: It was reported to (V3 Assistant Director of Nursing/ADON) that (R1) had a finger injury. Upon investigation, it was discovered that (V7 Certified Nursing Assistant/CNA) had been undressing R1 when his finger became caught in his shirt. While V7 CNA was removing (R1's) shirt, his third digit on his right contracted hand got caught on his shirt as it as being pulled off. R1 states it hurt his finger, but it happened so quickly that it was unable to be stopped. The facility's Daily Assignment Sheet, dated 1/8/24, documents V7 and V8 Certified Nursing Assistants/CNAs worked on the night shift and were R1's CNAs when he sustained injury to his middle finger on right hand. R1's diagnosis includes: hemiplegia and hemiparesis affecting right dominant side, contracture right hand. R1's current Care Plan documents: Self-care deficit as evidence by: Needs assistance with Activities of Daily Living/ADLs related to weakness to right side related to recent Cardiovascular Accident/CVA and contracture of the right hand. R1's Minimum Data Set (MDS) (Dated 11/20/23) documents R1 has a BIMS (Brief Interview of Mental Status) score of 12. (MDS indicates that on a scale of 0 - 15, 13 to 15 cognitively intact; 8 to 12 moderate impairment; and 0 to 7 severe impairment.) On 1/30/24 at 12:35pm, V5 Certified Nursing Assistant/CNA stated that R1 has to be dressed a Page 1 of 2 145691 145691 01/31/2024 Hallmark Healthcare of Pekin 2501 Allentown Road Pekin, IL 61554

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few certain way due to right sided weakness from a stroke and stated that R1's right hand was a little contracted. On 1/30/24 at 12:55pm, R1 stated that two Certified Nursing Assistants/CNAs (identified as V7 and V8) were assisting him to get undressed for bed on 1/8/24. Stated that his middle finger on right hand got injured when it got stuck in the sleeve while (V7 CNA) was taking his flannel shirt off; stated that he yelled stop' at that time. At this same time, R1 also stated that his right hand does hurt when it is moved; stated that the facility sent him to the Emergency Department/ED a couple of days later when his hand began hurting. R1 stated, They looked at my hand; that's about it; I think they X-rayed it. On 1/30/24 at 3:10pm, V7 Certified Nursing Assistant/CNA stated that she was R1's CNA on 1/8/24 when his finger injury occurred; V7 stated she was not aware of his right hand being contracted. V7 CNA stated, No one told me about R1. On 1/31/24 at 9:50am, V4 EMT/Emergency Medical Transport stated that they transferred R1 to the ED on 1/11/24. V4 EMT stated, (R1's) finger was red and swollen with lots of pain, substantial amount when trying to move the finger. On 1/31/24 at 12:55pm, V3 Assistant Director of Nursing/ADON stated that there was no treatment for (R1) prior to therapy reporting his pain on 1/10/24; V3 stated that nursing staff had not noticed R1's swelling. V3 stated, The protocol would have been the standing order--to do ice and elevation treatment. At this time, V3 ADON also stated and showed that she entered the standing order for ice and elevation for R1's injury in the facility's Electronic Health Record (Treatment Administration Record/TAR); order date 1/11/24; stated and showed there was no staff signage on the order. V3 ADON stated, I put the order in under Other and nursing staff did not see the order to sign off on. (R1) has not had treatment for his hand. The facility's Accidents and Incidents Policy, dated 9/7/23, documents: Purpose: To provide staff with guidelines for investigating, reporting, and recording Accidents and incidents. An accident/incident is any occurrence which is not consistent with the routine operation of the facility or the routine care of a particular resident It may involve injury or damage to property. The facility's (State) Long-Term Care Ombudsman Program Residents' Rights, dated 11/2018, documents, Your rights to safety: Your facility must provide services to keep your physical and mental health, at their highest practical levels. 145691 Page 2 of 2