Health inspection·March 25, 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 the facility failed to supervise a resident who was at risk for falls due to history of falls and failed to put specific fall intervention in place to prevent further falls, this failure resulted in R3 sustaining a nasal fracture and left forehead lacerations requiring stitches for 1 of 3 residents reviewed for falls in the sample of 6. The findings include: R3's face sheet show R3 is 76 y/o with diagnoses that include chronic venous hypertension, kidney failure and heart disease. R3's fall risk assessment dated [DATE] shows R3 is HIGH risk for falls. A Facility Reported Incident dated 3/22/24 (initial) show, At 1 pm, NOD (Nurse on duty) responded to a call for help from the room. Resident noted lying face down on then floor with wheelchair behind her. No loss of consciousness. Resident alert and oriented and verbally responsive. Residents states that she dropped something on the floor and wanted to pick it up, but resident unable to recall what item. Rapid response and 911 called. Resident noted with lacerations on left eyebrow, bridge of nose, left elbow, and left foot. Pressure applied to all areas, ice pack in place. R3's Hospital Records dated 3/22/24 show, pt arrives (from nursing home) c/o (complaint of) fall out of wheelchair, states she was reaching for something on the floor , reached too far, lost her balance and fell out of w/c striking face onto floor, laceration to forehead, skin tear to left elbow . CT scan of face results dated 3/22/24: bilateral acute nasal bone fracture. There is a laceration and small to moderate-sized soft tissue swelling involving the left forehead . diagnoses,complex laceration of left eyebrow, contusion of face, skin tear left elbow. R3's Hospital discharge instructions show, you have a bilateral fractured nasal bones and laceration above left elbow. Sutures will need to be removed in 7 days. R3's progress notes dated 3/22/34 show, x-rays- nasal bone fracture, R3's laceration above the left eye has 6 sutures in place, sutures have to be removed in 7 days. On 3/25/24 at 9:30 AM, R3 was in bed alert. R3 has deep dark purple bruising from the top of her forehead to underneath both of her eyes to her nasal area. There was stitches noted above her left eyebrow. When asked what happened, R3 said she was in her wheelchair, she thought something was on the Page 1 of 2 145923 145923 03/25/2024 Warren Barr North Shore 2773 Skokie Valley Road Highland Park, IL 60035

F 0689 floor so she leaned forward and fell. R3 said that was all she can remember. Level of Harm - Actual harm On 3/25/24 at 12:30 PM, V9 (License Practical Nurse-LPN) said she was the Nurse working last 3/22/24. V9 (LPN) said it happened around lunch time. V9 said R3 was found facedown on the floor, her wheelchair behind her. There was poll of blood around R3's head. R3 had fallen forward from her wheelchair. V9 said 911 was called and R3 was sent to a local hospital. V9 said R3 had a fall last month, (R3 fell out of her wheelchair inside her room reaching for something.) V9 said R3's room is in the middle of the hallway, far from the Nurses Station where staff usually are. R3's room cannot be seen when in the Nurses Station so R3 cannot be supervised. V9 said there was also no device to alert staff when R3 was trying to reach too far when in her wheelchair to prevent her from falling forward. Residents Affected - Few R3's fall careplan dated 2/2/24 show R3 is high risk for falls due to recent fall, poor safety awareness, impaired balance due to disease process. She has a habit of reaching/bending down to obtain items from the floor despite education and redirection. She requires max weight bearing assistance with bed mobility, transfers locomotion and toileting. She is noted to experience dizziness when changing position. She utilizes wheelchair as a primary mode of locomotion at this time. R3's fall interventions did not address R3's behavior of reaching/bending until today, 3/25/24 when surveyor was at the facility investigating R3's fall. The facility policy dated 7/1/7/23 entitled Fall Occurrence show It is the policy to ensure that residents are assessed for risk for falls, that intervention are reevaluated and revised as necessary. On 3/25/24 at 1PM, V2 (Director of Nursing) said they will be looking for R3's room placement and ways for R3 being monitored closer. 145923 Page 2 of 2