Health inspection·October 1, 2024

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 safely transfer a resident (R1) by mechanical lift from a geriatric chair to bed. This failure resulted in R1 being hit in the shoulder by the mechanical lift equipment causing a hematoma to R1's shoulder and R1's foot becoming caught in R1's geriatric chair causing a fracture. R1 is one of three residents reviewed for accidents in the sample of three. Findings include: The facility Transfers-Manual Gait Belt and Mechanical Lift Policy (revised 1/19/18) documents the following: In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility will use mechanical lifting devices for the lifting and movement of residents. Mechanical lifting devices shall be used for any resident needing a two person assist, or who cannot be transferred comfortably and/or safely by normal transfer technique. The transfer needs of residents will be assessed on an ongoing basis and designated into one of the following categories: H-Mechanical Lift with two caregivers. R1's Face Sheet dated 10/1/24 documents R1 is on Hospice and R1's diagnoses include: Alzheimer's Disease, Dementia, Hypothyroidism, Hypertension, and Pulmonary Fibrosis. R1's Medical Record does not document R1 as having any underlying bone diseases. R1's Comprehensive assessment dated [DATE] documents R1 is severely cognitively impaired with no upper or lower limb impairments, uses a wheelchair (geriatric chair) for mobility, and is dependent on staff for all activities of daily living (ADL) including transfers. R1's Care Plan (current) documents R1 has ADL self-care deficit related to impaired balance, Alzheimer's/Dementia, uses a mechanical lift for transfers and a geriatric chair for mobility. This same record documents for chair to bed/bed to chair transfers, R1 requires two staff with a mechanical lift. The facility investigation report dated 9/15/24 documents R1 was observed by the nurse (V4) exhibiting signs and symptoms of pain and decreased range of motion (ROM) to the left lower extremity. This same report documents R1 was assessed by the nurse and bruise to left shoulder was observed and V17 R1's Representative refused x-rays until 9/17/24. Further documents R1 diagnosed with a left distal femoral fracture on 9/18/24 and knee immobilizer in place. The same report documents V3 Certified Nurses Assistant (CNA) found to have improperly transferred R1 with a mechanical lift without assistance. Page 1 of 2 145911 145911 10/01/2024 Goldwater Care Gibson City 620 East First Street Gibson City, IL 60936

F 0689 Level of Harm - Actual harm Residents Affected - Few R1's Hospice Note dated 9/15/24 at 9:40am, documents R1 has new bruise/swelling/abrasion noted to left shoulder. R1 also has new onset of severe pain to left hip/leg when being changed in bed. R1 screaming in pain and PRN (as needed) Morphine (Opioid pain medication used to treat severe pain) administered. R1's Medication Administration Record (September 2024) documents R1 had been prescribed Morphine 100 milligrams/5 milliliters (ml), give 0.25 ml by mouth every two hours as needed for pain/air hunger. This same record documents R1 was administered Morphine on 9/15/24 at 9:27am, 12:05pm, and 4:39pm for pain. There are no other administrations of Morphine to R1 during the month of September prior to 9/15/24. R1's Left Knee x-ray dated 9/18/24 documents the following: left knee pain. Impression: Distal femoral fracture. On 10/1/24 at 11:42am, V1 Administrator stated based on the facility investigation, the facility concluded R1's injuries are due to an improper transfer with one person. V1 stated R1 is a mechanical lift transfer and none of the staff stated they assisted V3 CNA during the transfer of R1. V1 stated the investigation revealed V3 transferred R1 from bed to geriatric chair and from geriatric chair back to bed by self on the evening of 9/15/24. V1 stated during one of these transfers of R1, the lift arm came down and hit R1 on the left shoulder causing the bruise and R1's foot became caught in the gap between seat of R1's geriatric chair and footrest. V1 stated V3 did admit to transferring R1 out of bed to R1's geriatric chair by self. V1 stated V3 was suspended pending investigation and subsequently quit. On 10/1/24 at 1:31pm, V4 Licensed Practical Nurse stated V4 worked 9/15/24 and noticed the bruise to R1's shoulder and had not noticed it prior to 9/15/24. V4 stated the CNA's also reported it to V4 and also stated they had not seen it before. V4 stated, us nurses are big on telling our support staff to ask for help and to transfer appropriately. We are always available to help. On 10/1/24 at 1:58pm, V7 CNA stated V7 came in on 9/14/24 and worked 5:00pm to 9:00pm. V7 stated V7 worked the hall with V3 CNA that evening. V7 stated V7 did not assist V3 in getting R1 up for dinner as V7 was not in the facility at that time. V7 stated R1 was already in the dining room when V7 arrived. V7 stated V3 went on break around 6:15pm and V7 did not put any of the mechanical lift residents down by V7's self. V7 stated R1 was in R1's room at this time but resting in R1's geriatric chair. V7 stated when V3 returned from break, V7 went on break. V7 stated when V7 returned from break R1 was in bed. V7 stated V7 did not assist V3 with transferring R1 back into bed with V3. On 10/1/24 at 2:35pm, V2 Director of Nursing stated all nursing staff have been educated on safe mechanical lift transfers. V2 stated the facility has plenty of staff and even nurse managers help on the floor. 145911 Page 2 of 2