Health inspection·April 26, 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 Based on interview and record review, the facility failed to provide safe and effective supervision of R1 during a transfer to prevent a traumatic fall. This failure resulted in R1 falling from a mechanical lift to the floor resulting in a hip fracture requiring emergency medical treatment and surgical repair at the hospital. R1 is one of four residents reviewed for accidents in the sample of four. Findings include: R1's medical diagnosis list (4/25/2024) documents R1's diagnoses include: Muscle Weakness, Paraplegia, History of Cerebral Infarction (partial brain tissue death due to disruption in blood flow), Osteoarthritis, Presence of Artificial Knee Joint, Apraxia (neurological disorder causing difficulty with skilled movements even when a person has the ability and desire to do them), Dementia, Major Depression Disorder, and Anxiety Disorder. R1's quarterly assessment (2/6/2024) documents R1 has severely impaired cognition, upper and lower extremity impairment limiting range of motion, and is completely dependent on staff for all activities of daily living. The same record documents R1 requires staff assistance to transfer from a chair to a bed. The facility Incident Report and Investigation (4/7/2024) documents V3 (Certified Nurse Aide) and V4 (Certified Nurse Aide) were transferring R1 from R1's reclining chair to R1's bed on 4/6/2024 using a sling and mechanical lift. The report further documents when V3 lifted R1's legs, one of the four main straps attaching the sling to the lift slipped free from the lift causing R1 to fall abruptly to the ground striking R1's left hip onto the metal frame of the lift. The same report documents upon assessment, R1's left leg was externally rotated and shortened after the fall and R1 was sent to the hospital emergency department for evaluation and treatment and subsequently was admitted to the hospital for a hip fracture and received surgery on 4/7/2024. The hospital Emergency Department report (4/6/2024) documents R1 presented to the department after a fall from a lift in the nursing home for evaluation of left hip pain and a head injury (hematoma) and received fentanyl (narcotic medication used to treat severe pain) while in the emergency department. The same record documents R1 was diagnosed with a hip fracture and received orthopedic surgery on 4/7/2024. On 4/26/2024 at 11:50 AM, V3 reported, (R1) was kinda shocked at first (after falling from the lift to the ground) then started yelling in pain. (The) EMT (Emergency Medical Technicians) gave (R1) Fentanyl (narcotic medication used to treat severe pain) and (R1) was still screaming afterwards and Page 1 of 2 145953 145953 04/26/2024 Prairieview Lutheran Home 403 North Fourth Street Danforth, IL 60930

F 0689 they were wondering if (R1) was just scared. V3 reported R1 hit R1's head on the floor during the fall and R1 is still experiencing pain when staff move R1's leg. Level of Harm - Actual harm Residents Affected - Few On 4/26/2024 at 1:08 PM, V4 reported V4 and V3 had positioned R1 in the lift sling and R1 had been elevated into the air above R1's chair and when V3 adjusted R1's legs, the top left sling loop attached to the lift became free and R1 fell to the ground. V4 reported R1 continued to yell out in pain after falling from the lift to the ground. V4 reported attending a facility in-service after R1's fall where facility staff were instructed on making sure slings are attached properly when using mechanical lifts to transfer residents. R1's Order sheet (4/26/2024) documents R1 was ordered tramadol (narcotic medication used to treat moderate to severe pain) and daily surgical wound antiseptic treatment upon returning to the nursing home after R1's fall on 4/6/2024. R1's Care Plan (4/26/2024) documents R1 is at risk for falls and was revised on 4/8/2024 with the new fall intervention Staff education on (mechanical lift) use. 145953 Page 2 of 2