Health inspection·January 24, 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 observation, interview and record review the facility failed to ensure a mechanical lift (Hoyer) was used to safely transfer a resident to bed for 1 of 3 residents (R1) reviewed for safety in the sample of 3. This failure resulted in R1 being sent to the hospital with a laceration to her right posterior thigh that required 9 stitches after being transferred with a sit to stand lift. The findings include: R1's Face Sheet shows that she was admitted to the facility on [DATE] with diagnoses of end stage renal disease, lack of coordination, hypotension, dependence on renal dialysis, anemia, abnormalities of gait, abnormal posture and bradycardia. R1's Minimum Data Set assessment dated [DATE] shows that R1 requires substantial/maximal assistance to roll from left to right and is dependent on staff to move from sitting to lying, lying to sitting on side of bed, sit to stand and chair/bed to chair transfers. On 1/24/24 at 10:17 AM, R1 was laying in bed. R1 had a bandage to her right mid-posterior thigh. R1's Facility Incident Report dated 1/20/24 shows, On 1/16/24 around 5:00 PM patient was being transferred from the wheelchair to the bed with the sit to stand machine, her right knee buckle and she slid down during transfer. The patient did not make contact with the floor. Patient slid down by the bed where she was laid back down. When asked what happened, the patient stated that her legs became weak suddenly. Bleeding was noted on her pants, on the posterior right thigh skin tear was noted on the posterior right thigh ordered to send patient to ER (Emergency Room) for further evaluation and treatment. Patient returned to the facility within couple of hours with stitches present on right posterior thigh. R1's After Visit Summary from the local hospital dated 1/16/24 shows a diagnosis of: laceration of right lower extremity. R1's Wound Assessment Details Report dated 1/17/24 shows R1 has a wound on the right posterior thigh measuring 9 centimeters (cm) x 7 cm x 0.2 cm with 9 stitches present. R1's Change in Condition Form dated 1/16/24 shows, the patient had a skin tear during the sit to stand transfer machine, the patient was sent out due to skin tear needing stitches, before ambulance transferred patient to ER, PRN (as needed) pain medication was administered . Page 1 of 2 145923 145923 01/24/2024 Warren Barr North Shore 2773 Skokie Valley Road Highland Park, IL 60035

F 0689 Level of Harm - Actual harm Residents Affected - Few R1's Medical Professional Progress Note dated 1/17/24 shows, She was sent from the facility due to buckling of the knees and obtained a deep laceration to her left thigh. Per hospital records, stitches were placed . On 1/24/24 at 1:34 PM, V10 (Nurse Practitioner) stated she heard about the incident with R1. V10 stated that she heard R1's knees buckled during a transfer and obtained a laceration on her right thigh that required sutures. V10 stated she is not aware of what R1's transfer status was at the time of the incident but the staff should be following whatever therapy recommends for a safe transfer. On 1/24/24 at 11:57 AM, V5 (Certified Nursing Assistant) stated that she was transferring R1 from her wheelchair to the bed using a sit to stand lift when her legs started giving out. V5 stated when they got her into bed, they noticed blood coming from the back of her pants. V5 stated she and V8 (Licensed Practical Nurse) took down her pants and noticed a skin tear. At 2:30 PM, V5 stated she checked with the patient and the nurse on how R1 transfers, and they both said a sit to stand so that is what she used. On 1/24/24 at 12:08 PM, V8 stated that he was assisting V5 with a sit to stand transfer of R1. V8 stated during the transfer, R1's right leg buckled a little bit. V8 stated R1's feet did stay on the base of the machine, but he is not sure that her knees stayed up against the machine. V8 state, She just slid a bit. On 1/24/24 at 12:58 PM, V9 (Therapy Director) stated if a resident is in physical therapy, the therapy department communicates with the nursing staff to let them know how a resident is able to safely transfer. V9 stated R1 has been a mechanical lift (Hoyer) transfer since her admission and therapy had just started working with her on safely using the sit to stand lift. V9 stated R1 just started using the sit to stand lift with the therapist on 1/12/24. V9 stated the sit to stand was used on 1/12/24 but was not attempted during her therapy sessions on 1/14/24 and 1/15/24. V9 stated the nursing staff should have been using the mechanical lift (Hoyer) to safely transfer R1 since they had not given the recommendation to the nursing staff to upgrade her transfer status to a sit to stand. V9 stated R1 still has days that she is weaker, especially on her dialysis days. On 1:48 PM, V2 (Director of Nursing) stated physical therapy or restorative therapy if they are in therapy can upgrade a resident's transfer status. V2 stated the departments communicate with the nursing staff on what way the resident is able to transfer safely. R1's Fall Care Plan initiated on 12/18/23 shows R1 transfers between surfaces using a mechanical lift (Hoyer) due to fear of falling. Interventions include PT/OT (physical therapy/occupational therapy) to treat as ordered to increase strength and mobility and prevent further falls. 145923 Page 2 of 2