Health inspection·September 27, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records reviewed the facility failed to ensure medical records for one resident are complete and accurately documented by containing accurate and complete restorative assessments and interventions to address care plan needs. This affected one of three residents (R1) reviewed for medical records. The findings include: R1's diagnosis include, but are not limited to Vertebra Fracture, Cognitive Communication Deficit, Unspecified Symptoms and Signs Involving the Nervous System, History of Falling, Dementia, Depression, Anxiety, and Osteoarthritis. Incident report provided to IDPH states on [DATE] R1 complained of pain to the right shoulder. X-rays were obtained with findings of acute appearing clavicle fracture. R1 was sent for evaluation to the hospital on [DATE] and returned the same day to the facility. R1 was a hospice patient and died on [DATE]. On [DATE] at 12:48PM V2, Restorative CNA, said R1 was on a turning and repositioning program. V2 said R1 can turn but needed 2 person assistance turning. There was no documentation of this program in the records. On [DATE] at 2:07PM V7, CNA, said it was hard for R1 to turn on the right, she was about to cry. V7 said this was something new. V7 said, I don't remember if the nurses knew about it. I had R1 10-15 times. There was no documentation of this in R1's chart. On [DATE] at 2:15PM V8, CNA, said R1 was afraid to turn because she feared falling out of bed. V8 said before [DATE] R1 was 1 person assist for turning. On [DATE] at 2:30PM V3, Director of Nursing, said there is no risk management (incident report) for R1's injury. V3 said, I was told the IDPH reportable serves as the documentation. The surveyor asked how someone would know the resident's status regarding R1 new injury. V3 responded, We would know something happened based on the IDPH report and any x-rays. V3 said the IDPH reportable and risk watch (incident reports) are not part of the resident chart. V3 said it would be very important for providers to know if a fall or incident occurred. On [DATE] at 10:17AM V3 said, We do a root cause analysis on everyone. We have a separate binder for that. V3 said the purpose of the root cause analysis is to analyze the situation and determine if something can be done differently to prevent event from happening again. The surveyor reviewed R1's incident report with V3. V3 said R1 had some blood under his nails and some dried abrasions on his knee. V3 said we did an incident report on R1 in case R1 fell or complications occur later. The Page 1 of 2 145893 145893 09/27/2024 Harmony Palos 11860 Southwest Highway Palos Heights, IL 60463

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few surveyor discussed R1's injury and documentation compared to R1's documentation. V3 said R1 required probably 1 CNA to turn. V3 said, I am not sure how many CNAs were being used but [R1] was not independent with turning. V3 said R1 did not struggle to get her to move. V3 said an incident report was not done for R1 because it was determined R1 did not have a fall. V3 said an incident report was not required. V3 said the doctor documented the pain, x-ray, and ordered a sling. V3 said R1 had an incident of a serious injury. V3 said a pain assessment should be completed for R1 having pain on [DATE]. Review of R1's incident report dated [DATE] classified as other completed. R1 has no incident report for [DATE]. The facility nurse did not document a pain assessment on [DATE] to include type of pain, severity of pain, or interventions outcome. There is no documentation in R1's facility record to indicate the injury was an expected outcome related to her medical condition or diagnosis. R1's record has no documented additional interventions to prevent a similar injury from reoccurring. Review of R1's physician orders has no order for pain assessments. Review of R1's restorative assessments performed by the surveyor on [DATE] before 2:30PM, assessments were not complete and remained open. Responses were not entered for all questions. After 3:00PM when the surveyor looked at the restorative assessment during the interview with V10, both assessments were filled out with date of [DATE] at 2:59 PM and 3:04PM. On [DATE] 11:05pm V13, Restorative Nurse, said R1's assessments were open, someone called me and said state was there and I had to fill them out and locked them yesterday. The facility care plan for R1 was reviewed on [DATE] by the surveyor. Care plan includes risk for alteration in musculoskeletal status related to T8 vertebral fracture, gout, osteopenia. Dated [DATE]. Care plan risk for pain related to T8 vertebral fracture, gout, OA, history fall, Depression, GERD, history of breast cancer. Dated [DATE]. The facility printed care plan presented on [DATE] pages 9 and 26 now include right clavicle fracture. (This change was made to the care plan at least 27 days after her death.) Facility policy for documentation was requested on [DATE]. No policy was provided. Facility policy for incident/accident procedures dated [DATE] states an accident/incident report must be completed by the nurse for all incidents/accidents including injuries of unknown source. 145893 Page 2 of 2