Health inspection·April 30, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure interventions/hip precautions were used to keep a resident's left hip prosthetic in place. This applies to 1 of 3 residents (R1) reviewed for quality of care in the sample of 3. Residents Affected - Few The findings include: R1's EMR (Electronic Medical Record) shows that R1 was admitted to the facility on [DATE] with diagnoses including Periprosthetic Fracture around Internal Prosthetic Left Hip Joint, Difficulty in Walking, Chronic Obstructive Pulmonary Disease, Parkinson's Disease and Dementia. R1's Progress Notes dated 3/9/24 state, Received patient in bed Alert and Oriented x 1-2. Patient complained of increased pain to left hip 10/10. Oxycodone (Narcotic Analgesic) given at this time. (Physician) covering for (Primary Physician) made aware of increased pain with order for STAT X-Ray to left hip. (Portable X-Ray) made aware of STAT order. Called into patient's room upon assessment noted bloody drainage to surgical incision site and raised bump to left hip proximal to surgical incision site. Patient unable to straighten surgical left leg. New pressure dressing applied. (Physician) notified of change in drainage and raised bump with order to send patient to ER via (Private) ambulance for further evaluation. Patient notified of new orders and agreeable. Patient's wife made aware of above matter and appreciative of call. Patient left facility at 11 AM . R1's Progress Notes dated 3/9/24 state, Called (Local) Hospital, spoke to RN (Registered Nurse), patient diagnosed with dislocation of left hip and scheduled for closed hip reduction tomorrow. R1's EMR shows that he returned to the facility on 3/19/24. R1's Physician's Order Sheet shows an order dated 3/19/24 for knee immobilizer at all times and strict posterior hip precautions abduction pillow at all times. R1's Progress Notes dated 4/23/24 state, (Change in Condition) Physical Therapist noticed left leg shortened and internal rotated. Right hip more swollen and complains of pain unable to stand up. R1's Physical Therapy Treatment Encounter Note dated 4/23/24 states, Precautions/ Contraindications: WBAT (Weight Bearing as tolerated LLE (left lower extremity) [NAME] (?) at all times, posterior hip precautions, abduction pillow at all times in bed . R1's Final Report of the incident on 4/23/24 states, While at the hospital X-Ray results of the left hip showed: superior lateral dislocation of the femoral head component of the patient's left hip Page 1 of 2 145706 145706 04/30/2024 Whitehall of Deerfield 300 Waukegan Road Deerfield, IL 60015

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hemiarthroplasty; there is a questionable avulsion fracture of the greater Trochanter. Patient was transferred to (local) hospital for surgery. While at (local) hospital, it was decided to put surgery on hold as patient's family wanted to review options and whether or not to go forward with surgery or pursue hospice . On 4/30/24 at 10:30 AM V9 (RN) stated, Therapy had gotten him up and they noticed a lot of pain. They noticed the shortening and internal rotation of the left leg. Therapy often gets them up. They come around 7:30 AM. I have no clue what happened. I sent him to the hospital, and he did not come back. I haven't heard any more about him. On 4/30/24 at 11:06 AM V5 (Physical Therapist) stated, That morning (4/23/24) I found the hip dislocation. He had a history of it in the past. He had a tendency for his leg to roll inward in bed. I wanted to get him up and assess him. He was not able to stand or place any weight on that leg (left). There was usually a wedge (abductor pillow) in the bed but that morning I don't recall there being one there. We always recommend the wedge if they are cognitively impaired and need it to maintain hip precautions. I also saw him on 4/22/24 and he was much better. He usually needed just stand guard assist but on the 23rd he needed moderate assist to try to stand. I noticed something was different with him right away. On 4/30/24 at 11:50 AM V7 (CNA) stated, When I come in, they are usually in bed. R1 is restless in the bed and often throws his legs out of the bed. I have to go in there many times to reposition him. I put the pillows in between his legs and reposition him. He throws the pillow out. R1 is incontinent and he doesn't ever ask for the urinal. The last time I rounded with R1 was probably about 6-6:30 AM. 145706 Page 2 of 2