Health inspection·February 10, 2025

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: The nursing home is disputing this citation. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview and record review, the facility failed to provide safe and effective supervision during a total body mechanical lift transfer to prevent a traumatic fall. This failure resulted in R1 falling from R1's transfer sling, striking R1's head on an adjacent bedside table, and landing on the floor, resulting in a collarbone fracture and scalp laceration requiring emergency medical treatment at the hospital. R1 is one of three residents reviewed for accidents in the sample of three. Findings include: R1's medical diagnosis list dated 2/6/25 documents R1's diagnoses include: Neuropathy, Left Knee Pain, Hyperlipidemia, Arthritis, Anxiety, and Depression. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has severely impaired cognition and is totally dependent on staff for transfers. On 2/10/2025 at 09:50 AM, V4 Certified Nursing Assistant (CNA) and V5 Certified Nursing Assistant reported R1's transfer is supposed to be completed by two staff members using the total body mechanical lift. On 2/10/25 at 12:13 PM V8 CNA stated that (on 1/5/25) V8 was behind the total body mechanical lift, using the remote and lifted R1 from the bed while V7 CNA was at R1's wheelchair, and V8 began moving R1 from over the bed to towards the wheelchair. V8 stated V8 heard a click, the left clip of the sling near the left shoulder came undone, and R1 fell from the sling, landing on the floor. V8 stated R1 yelled in pain, and V8 went to get the nurse. V8 stated no staff was near or supporting R1 while V8 was moving the lift. The facility incident report dated 1/13/2025 documents V7/V8 (Certified Nurse Aides) were providing a total body mechanical lift transfer for R1 on 1/5/2025 from the bed to the wheelchair. The same report documents V8 moved the total body mechanical lift after lifting R1 from the bed while V7 was adjusting the wheelchair, and the securing clip from the sling to the lift came undone, causing R1 to fall onto the floor and R1 was sent to the hospital emergency department for evaluation and treatment. The report does not document any other staff were present during V7/V8's transfer of R1 on 1/5/2025. The hospital report dated 1/5/2025 documents that facility staff reported R1 had a fall from the total body mechanical lift on 1/5/2025. The same record documents R1 sustained a left clavicle (collarbone) fracture and scalp laceration requiring staples as a result of the fall. The report documents Page 1 of 2 145883 145883 02/10/2025 Piatt County Nursing Home 1111 N State St Monticello, IL 61856

F 0689 R1 complained of pain while in the emergency department and received narcotic pain medication. Level of Harm - Actual harm The facility incident investigation dated 1/5/2025-1/13/2025 documents a signed witness statement from V7 (Certified Nurse Aide) describing R1's fall on 1/5/2025. V7's statement documents R1 was in the sling attached to the total body mechanical lift when V7 was behind R1's wheelchair adjusting linens, and R1 attempted to position R1's self after V8 moved R1 from over the bed and R1 fell from the lift onto R1's left side on the floor and was yelling in pain. V7 reportedly instructed for V8 to get the nurse. Residents Affected - Few Note: The nursing home is disputing this citation. The facility incident investigation dated 1/5/2025-1/13/2025 documents a signed witness statement from V8 (Certified Nurse Aide) describing R1's fall on 1/5/2025. V8's statement documents R1 was in the sling attached to the total body mechanical lift when V8 moved R1 away from the bed and R1 adjusted R1's self. V8 documents hearing a click, and R1 fell from the sling. V8 documents are going to get the nurse after the fall. The report dated 1/5/25 documents V11 Licensed Practical Nurse being called to the room per CNA. The report documents R1 laying on the floor on his stomach, with bleeding noted from the left side of R1's head. The report documents R1 complained of pain to the left hand which he was laying on. The report documents R1 was being transferred per mechanical lift, and R1 was unable to give a description of the incident due to pain. The report documents R1 complained of left hand/arm pain and an ambulance was called to transport R1 to the hospital. The facility In-Service attendance roster dated 1/6/2025 documents facility nursing staff received training to use two staff for total body mechanical lift and procedures. On 2/10/25 at 1:28PM V9 Restorative CNA provided a document that states all new hires are trained immediately upon hire that two staff assist with all lift transfers. One staff to manage the lift and one staff to support the resident hands on. On 2/6/25 at 09:45 AM V1 Administrator provided a policy titled Lift Machine, Using a Mechanical dated 2001, with revision dates 2017 and 1/2025. Line One documents that at least two trained staff are needed to safely move a resident with a mechanical lift. Line Twelve documents to gently support the resident as she/he is moved. 145883 Page 2 of 2