145923
11/26/2024
Warren Barr North Shore
2773 Skokie Valley Road Highland Park, IL 60035
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 ensure a resident was repositioned safely. This failure resulted in R1 sustaining a intertrochanteric (thigh/femur/hip bone) fracture that required an open reduction surgery. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 12. The findings include: On November 23, 2024 at 1:08 PM, R1 stated, V11 Certified Nursing Assistant (CNA) came to her room to change her multiple times. She refused to have V11 change her because she felt like she was rough with her. She refused to be changed two times. The third time, V11 CNA told her she was going to get changed and threw her legs over the rail and she heard a pop. After that she had pain in her left leg. She stated, she (V11) would not listen to nothing. Told her don't touch me and no, thank you. Now, I have to suffer for my hip fracture and have surgery. I might not be able to walk again. R1 started crying and gave the phone to her daughter (V3). R1's local hospital records dated November 21, 2024 shows, General: admission H&P (history and physical): History of present illness: R1 is a 60F ([AGE] year old female) w PMH (with a past medial history of) GERD (gastroesophageal reflux disease), OSA (obstructive sleep apnea), bipolar 1, HTN/HLD (hypertension/hyperlipidemia), asthma, hip replacement 8/17 with V14 c/b (complicated by) recurrent prosthestic left hip joint infection w recent discharge on 11/13, discharged on vancomycin and cefepime (both antibiotics), pw (patient with) left hip pain. She was at the facility receiving antibiotics and stated that one of the staff was too rough with me when changing my diaper and felt a pop in the area, reporting pain in the left hip . Assessment & Plan: .Stated she was handled roughly by staff and heard a pop in her joint. XR (x-ray): Left revision total hip arthoplasty with acute comminuted periprosthetic fracture of the left intertrochanteric region as described . On November 23, 2024 at 3:38 PM, R12 (R1's room mate) stated, she woke up to R1 having a problem with someone. R1 was upset because they hurt her while turning her. It had to do with her being moved in bed. Apparently whatever the CNA did added to her pain. R1 complained of pain the next day. Then she left to the hospital. I was under the impression she was in more pain than normally. On November 24, 2024 at 9:05 PM, V11 CNA stated, she worked November 19th on the night shift (into November 20th morning). That night she went to R1's room to change her and R1 stated no. She went back again and told her no again. The third time she tried to change her, R1 told her no, don't touch me. She denied ever changing her or touching her that night. R1's task list for November 19, 2024 shows, she was incontinent during the night shift.
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145923
145923
11/26/2024
Warren Barr North Shore
2773 Skokie Valley Road Highland Park, IL 60035
F 0689
R1's change in condition form dated November 20, 2024 shows, Situation: patient is complaining of pain anytime you move the left leg.
Level of Harm - Actual harm
Residents Affected - Few
On November 26, 2024 at 11:04 AM, V13 Physician Assistant (PA) stated, he is part of R1's surgery team. R1 originally broke her left hip and had surgery back in August. She had an infection in the hip so they placed a cement spacer. She was sent to the facility following that cement spacer placement. They had followed up with her after and re-did x-rays, there was no fracture. When she came into the hospital this time she claimed staff was aggressive with her, twisted her leg and she heard a pop. The x-rays showed a fracture. She had surgery for an open reduction the day before (November 25th) with him. The fracture is caused by a twisting torsion type of injury. The only way to get the fracture is by twisting the leg. On November 24, 2024 at 9:50 PM, V15 Assistant Administrator stated, R1 told her V11 CNA tried to change her 3 times where she told her no and on the third time, she changed her. She moved her and heard a pop in her leg. V11 CNA, swears R1 refused to be changed three times. The facility's SNF/NF (skilled nursing facility/nursing facility) to hospital transfer form dated November 20, 2024 shows, R1 is dependent on staff for all ADL's (activities of daily living) and is incontinent of bowel and bladder. R1's minimum data set (MDS) shows, she is cognitively intact. R12's (R1's room mate) minimum data set (MDS) shows, she is cognitively intact. R1's care plan initiated on November 14, 2024 shows, Focus: R1 has an ADL Self Care Performance Deficit and Impaired Mobility r/t (related too) weakness, impaired balance, impaired balance and pain, therefore requires weight bearing assist with bed mobility, transfer, toileting, dressing, locomotion and walking. Comorbidities include: Infected left total hip Arthroplasty, AKI (acute kidney infection), Hypercalcemia, Anemia, Bipolar, HTN, Asthma, Obesity and OSA. Interventions: I would like staff to provide gentle range of motion as tolerated with daily care. BED MOBILITY: R1 use(s) assistive device (bed rails) to reposition and turn in bed. TOILET USE: [NAME] require(s) Max. staff participation to use toilet. The facility's resident council minutes for the month of September 2024 shows, Nursing/CNAs: Residents had some concerns about CNAs professionalism. Resident expressed 3rd shift is rough at times. CNAs tends to just get in and get out of rooms.
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