Health inspection·August 23, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to make sure a resident's call light was in place. Due to the call light not being in place, the resident fell out of bed and sustained an injury. This failure affects one of three residents (R2) reviewed for falls with injury in a total sample of three residents. Residents Affected - Few Findings include: R2 is [AGE] year-old male. R2's diagnoses are but not limited to high blood pressure, arthritis of both hips, and irregular heartbeat. R2's BIMS (Brief Interview for Mental Status) dated 07/23/2023, notes R2 is alert. R2's MDS (Minimum Data Set) dated 07/23/2023, notes R2 requires extensive two-person assistance. R2's fall risk assessment dated [DATE], notes R2 is high risk for falls and his call light must be in reach. Progress note dated 07/17/2023, notes night supervisor informed writer that resident was on the floor. Resident was yelling for help. Writer went in to see the resident and resident was on the floor lying on his right side. His head was under the bed. Staff moved the bed and began a body check. The resident yelled out when his right leg was moved. He was guarding his right hip. Also, there was a skin tear to his right hand and elbow. The resident was lifted off floor and placed in bed. The resident was reaching for the call light on the floor to call for assistance because he had a bowel movement. His skin tear was cleansed. The resident was moaning and groaning holding his right hip. Resident given pain medication for pain but remains in pain. Awaiting ambulance for pick up. Resident admitted to local hospital with diagnosis of closed right hip fracture. On 08/22/2023, at 12:28 PM, V3 (Certified Nursing Assistant) stated, I help R2. I have worked with him a few times that I have been here. He is a complete full assist. He needs help with everything as far as dressing, toileting and hygiene. He can reach the call light, but it must be near him. I have never seen him walk. He uses the mechanical lift and the mechanical standing device to be changed. I usually work first shift. I round on him every thirty minutes to make sure he is ok. Each resident is different. On 08/22/2023, at 12:30 PM, R2 stated, I reached too far. I was lying in bed, and I was trying to reach for the call light. The bed was at medium height. I cannot recall how they keep my bed. It was early in the morning. I was trying to get help. I do not remember what I needed help with. I need help to get up. When I must go to the bathroom, someone must help me. I think they came because I hit the floor hard. There was no padding. But there is padding now. If there was padding, I would not have broken anything. I would say this is the first time I have fallen out of bed. I wear an incontinence brief and staff change me. It still hurts, my right hip. There is a fall mat on the side of the Page 1 of 3 145904 145904 08/23/2023 Smith Village 2320 West 113th Place Chicago, IL 60643

F 0558 bed. Level of Harm - Minimal harm or potential for actual harm On 08/22/2023, at 12:35 PM, R2's call light was behind R2's bed. R2 was asked to reach for the call light. He could not reach for the call light. Instead R2 reached for his feet. Residents Affected - Few On 08/22/2023, at 12:52 PM, V4 (Licensed Practical Nurse) stated, I found him. I was not his nurse that night. I was in the office working on a report. I heard someone yelling help me. I walked down the hallway. As I was getting closer, I heard the yelling more prominently. I got to the doorway by his room. He was laying on the floor on the right side of the bed. His head was by the side of the bed. His legs were facing towards the doorway. His body was on the right side where he was facing towards the nightstand. I believe he had his blanket on the floor as well. I had asked him what happened. He was yelling to get him up. I told him to hold on and I needed to get help. I informed the nurse on the unit that he was on the floor. We both went back to the room and then I went to go get the aide that was helping him that night. The nurse was assessing him. I went to answer the call lights. The resident was in the bed. From the way he was yelling, I know he needed help. On 08/22/2023, at 1:03 PM, V5 (Former Licensed Practical Nurse) stated, I do not work with the facility anymore. They terminated me. The supervisor came and told me that R2 was on the floor. I was going that way anyway. I went down there, and he was on the floor. He was lying on his right hip. His head was little under the bed. He had feces on the bed and on the floor. It was wet. He was saying help me. I could not get him up by myself. With the help of the staff, we got him in bed and cleaned him up. He was still hollering about hip pain. I gave him some pain medication and called his power of attorney. He was complaining of hip pain. I called the physician. He told me I could send him out. I called the ambulance. This happened at 4:30 AM. Before 6:00 AM the ambulance was there to pick him up. I came back a couple of days later and they told me that he fractured his hip. This is what I was told by the aide. I was passing my medication at 4:00AM. He put the light on. He normally does not call unless he wants you to change him. He put the light on, and the aide went to go see what he wanted. He was asleep. In my opinion, she took too long to get to him. She did not wake him up to see what he wanted. He did not have the call light after she left. He was reaching for the call light, and he fell out of the bed trying to get it. He fell to the floor. Having the call light in reach is important so residents can call for help. He will holler out for help if the call light and his phone are not in place. I knew he had the call light when I was giving medication. If she would have had the call light in place this would have never happened. On 08/22/2023, at 1:14 PM, V6 (Certified Nursing Assistant) stated, He is normally on my case load. He is extensive with everything. He cannot walk at all. He can use the call light. The call light is supposed to always to be reach. He is at risk for a fall if his call light is not in reach. Before this fall he was able to stand and pivot. But now he is a complete assist with the mechanical lift. It takes two people to transfer him now. If he was able to push the call light instead of reaching for it this could have prevented his injury. On 08/22/2023, at 1:21 PM, V7 (Former Certified Nursing Assistant) stated, Between 3:55 AM and 4:30 AM, I heard the call light ringing. I went in there to check on him and he was sleeping. Sometimes the residents sleep on the lights. I switched off the light and did my rounds on other residents. Maybe five or ten minutes later, someone told me that there was a fall. When I got there, the nurse and the aide were in the room. R2 was in the floor. His incontinence brief was wet, and water had spilled on the floor. He had blood on his hand. I and the other aide put him in bed. He is not independent. He needs his brief changed. 145904 Page 2 of 3 145904 08/23/2023 Smith Village 2320 West 113th Place Chicago, IL 60643

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 08/22/2023, at 1:38 PM, V8 (Fall Coordinator) stated, I have reviewed R2's fall. I believe since I have become the fall coordinator this is his first fall. I would say he is a high risk for falls. According to his fall risk assessment, if you score a ten or higher, this puts the resident at high risk for falls. The root cause of the fall is him trying to reach his call light. I would say that his interventions were not in place because he should not have to reach for the call light. It should be in place. The issues I see after reviewing the interview with the aide is why didn't she check on him before the 4:20 AM? The best practice is to turn and reposition the residents every two hours. I would want to know where the call light was when she left the room. It is all situation based. In this situation, I would call his name to see what he wanted. Or stay longer in the room to see what he needed. The post fall assessment is filled out by the aide and the nurse. I would expect more information to be put on the sheet instead of non-applicable. I believe that is his call light was in reach, this would have prevented his injury. On 08/22/2023, at 2:10 PM, V9 (Director of Nursing) stated, The root cause of the fall is he needed to be toileted. He tried reaching for his call light and rolled out of bed. The call light should be within reach for the resident. It might have prevented his fall if the call light was in reach. There had been some rounding issues with the nurse and the aide previously. That is why they were let go because it became a problem. On 08/23/2023, at 4:26 PM, V10 (Medical Doctor) stated, Yes, they let me know about his fall. He is an old man. I am sure he has osteoporosis. He is very high risk for fracture due to his age and diagnoses. According to the facility, he fell out of bed reaching to the call light. Facility fall policy titled Fall Prevention Management, undated, notes call lights are clipped and secured to resident when in bed (sheet, gown, blanket, etc.) to prevent falling off, answer call lights in a timely manner. 145904 Page 3 of 3