145720
10/15/2025
St Clara's Rehab & Senior Care
1450 Castle Manor Drive Lincoln, IL 62656
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 follow its procedure for transportation and failed to adequately supervise and safely secure resident during transport to prevent a fall for one (R1) resident of three residents reviewed for accidents/incidents in a sample of three. These failures resulted in R1 sustaining a subdural hematoma and left scapula fracture. Findings include: The facility's (State) Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities, dated 11/28/18 documents: Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life; and, Your rights to safety: The facility must provide services to keep your physical and mental health, at their highest practical levels.The facility's Passenger Carrier Safety Orientation-Return Demonstration Procedure dated 5/21/2015 (Signed and Dated 9/10/25 by V5 licensed Practical Nurse/LPN) documents: Any employee who will be a designated driver of a passenger carrier must complete the assigned online training as well as behind the wheel training by the facility's designated driving coach. 9. Employee backs the resident into the van. 10. Employee securely fastens and secures the resident into the van. R1's Hospital Notes dated 9/27/25 document: Radiology Report: Impression: Left subdural hematoma along the posterior falx. Minimally displaced left scapular fracture medially. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has a BIMS (Brief Interview of Mental Status) score of 15. (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.) R1's diagnoses include: History of Transient Ischemic Attack (TIA), Cerebral Infarction, Hemiplegia and Hemiparesis affecting left non-dominant side, Type 2 Diabetes, Depression, Obstructive Sleep Apnea; Dementia with other behavior disturbance, psychotic disturbance, mood disturbance; Chronic obstructive pulmonary disease (COPD), Acquired absence of left leg above knee, Traumatic subdural hemorrhage without loss of consciousness, Displaced fracture of body of scapula, left shoulder. R1's recent Care Plan documents: (R1) is at risk for falls related to needing assist with mobility and transfers, history of fall; use of psychotropic medication, left above the knee amputation. (R1) has been noted to be non-compliant with non-weight bearing and not to wear shoes. Facility's Initial and Final Reports to (State Department of Public Health) for R1 dated 9/27/25 and 10/3/25 document: On 9/27/25 at (1:50am), (R1) was being transported via facility van from an (Emergency Room) evaluation, fell over backwards, hitting his head on the rear door of the van. (R1) was diagnosed with an intracranial bleed and was transferred to (City) Medical Center for admission. Conclusion: (R1) was transported to the (Emergency Room), was diagnosed with a superficial abrasion to the scalp, a left subdural hematoma along the posterior falx measuring 0.8 centimeters, and a minimally displaced left scapular fracture. (R1) returned to facility on 10/2/25. (Documentation and Interviews indicated that V5 Licensed Practical Nurse/LPN was the driver of the facility van on 9/27/25.) On 10/14/25 at 1255pm, V8 Transport/Certified Nursing Assistant/CNA, stated that she did train (V5 Licensed Practical Nurse/LPN)
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145720
145720
10/15/2025
St Clara's Rehab & Senior Care
1450 Castle Manor Drive Lincoln, IL 62656
F 0689
Level of Harm - Actual harm
Residents Affected - Few
on how to secure residents in the van during (V5's) transportation training and orientation. On 10/15/25 at 9:01am, V5 LPN stated that on the day of R1's accident, that V5 used the van for the first time; had just gotten his license to drive it to transport residents. V5 stated that he had been trained on how to secure wheelchairs in the van but that he only locked R1's wheelchair wheels and that was it, stated that the facility was only a block away (from hospital). V5 stated, It was around 1:30am in the morning; figured it was just a block away to the facility. I stopped at the stop sign out of the hospital parking lot; stepped on gas and (R1) rolled backwards. At this same time, V5 stated that he was no longer at the facility; stated I felt so bad about this; I resigned the next day. On 10/15/25 at 10:50am, V1 Administrator stated: (V3 Power of Attorney/POA to R1) was called after the accident. Both myself and (V3) agreed that the accident could have been avoided. When I called (V5 LPN) about the accident, he said he is getting too old for all the new technology; and said he was putting in his resignation immediately. (V5) was responsible for securing residents in the van.
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