Health inspection·September 13, 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 interviews and record review, the facility failed to follow its policy and properly transfer a resident with a mechanical lift device during a transfer procedure for one (R1) resident out of three residents reviewed for resident safety. This failure resulted in R1 sustaining a fracture of the right knee while being transferred in the facility. Findings include: Face sheet dated 09/12/2024, documents R1 is an [AGE] year-old female with diagnoses not limited to: Osteitis deformans, chronic embolism and thrombosis, hypothyroidism, hyperlipidemia, chronic kidney disease, hypertension, and vitamin D deficiency. R1's MDS (Minimum Data Set) dated 08/20/2024, documents R1 has a BIMS (Brief Interview for Mental Status) of 04/15 indicating R1 is severely cognitively impaired. R1's Activities of Daily Living (ADL) Assistance documents R1 is dependent with ADL care. R1 is dependent with transferring from bed to chair. R1's MDS documents walking activity for R1 did not occur. The activity of walking 10 feet was also not attempted for R1 due to R1's medical condition or safety concerns. On 09/12/2024 at 10:02AM, R1 observed sitting in the second floor dining room fully dressed and sitting in a Geri chair. R1 stated she fell while walking in the facility when she was in the basement. R1 stated she did not sustain any injuries. R1 noted with confusion during interview. On 09/12/2024 at 10:18AM, V2 (Director of Nursing) stated R1 did not experience a fall in the facility. V2 stated R1 was improperly transferred with a mechanical lift device by a CNA staff member (identified as V4/CNA). V2 stated V4 was a new staff member who was recently hired at the facility. V2 stated she was informed by the nurse (V3/LPN) R1 was reporting right knee pain, so the facility ordered an x-ray of R1's knee the same day. V2 stated R1's x-ray report documented R1 had a right knee fracture. V2 stated she then reported to the state agency R1 had an injury of unknown origin. V2 stated she then started an investigation and found out during her investigation V4 transferred R1 with a mechanical lift device alone without any assistance from other staff. V2 stated R1 requires the use of a mechanical lift device to be transferred and this requires two person assistance. V2 stated V4 terminated her own employment by not coming back to the facility after providing V2 with a statement. V4 no longer works at the facility. On 09/12/2024 at 10:39am V3 (Licensed Practical Nurse/LPN) stated she was assigned to work on the second floor of the facility and assigned to care for R1 on 08/13/2024. V3 stated she was made aware by the CNA (identified as V5/CNA) R1 was complaining of knee pain. V3 stated she went to R1's room Page 1 of 3 145977 145977 09/13/2024 South Shore Rehabilitation 2425 East 71st Street Chicago, IL 60649

F 0689 Level of Harm - Actual harm Residents Affected - Few and performed an assessment and R1's right knee was swollen. V3 stated she contacted R1's nurse practitioner/NP and made R1's NP aware of R1's knee status. V3 stated R1's NP was located inside of the facility during time and assessed R1 in person and ordered an x-ray to be performed on R1. V3 stated the x-ray company performed an X-ray on R1 the same day. V3 stated she administered pain medication to R1 while awaiting the ordered x-ray. V3 stated she asked R1 what happened but R1 was unable to give an account of what happened to R1's knee. V3 stated R1 is often confused. V3 stated she was made aware by R1's NP R1's x-ray report showed R1 had a fracture. V3 stated R1's NP order a knee brace for R1's right knee and ordered orthopedic appointments for follow up care. V3 stated she carried out the NP orders. V3 stated she contacted R1's POA/power of attorney and made her aware of R1's knee status. V3 stated R1's NP also gave orders to send R1 out to the ER to be evaluated. V3 stated R1's POA stated she did not want R1 to go to the ER but just wanted R1 to wait for her follow up appointment with the orthopedic. On 09/12/2024 at 11:23AM, V2 (DON) stated during her investigation, V2 spoke with V4 (CNA) via telephone to inquire about R1's knee. V2 stated V4 informed her V4 transferred R1 to a Geri chair without any assistance by pivoting R1's body into the chair. V2 stated she asked V4 the reason for pivoting R1 without assistance during transfer when R1 requires the use of a mechanical lift device with two person assistance. V2 stated V4 said V4 was aware R1 required the use of a mechanical lift device for transfers. V2 stated she made V4 aware she needed V4 to come into the facility to speak with V2. V2 stated V4 agreed to come into the facility but never came back into the facility to speak with her. V2 stated she still has not heard from V4 since then. V2 stated she believes the pressure from V4 pivoting R1 is what caused R1's right knee fracture. V2 stated R1's resident care card is kept in R1's room and visible for staff to see. An attempt to contact V4 (Certified Nursing Assistant/CNA) was made on 09/12/2024 at 12:05PM, unable to leave voicemail due to voice mail being full. On 09/12/2024 at 12:11PM, V5 (CNA) stated she was the CNA responsible for caring for R1 on 08/13/2024. V5 stated while she was performing rounds, R1 groaned and told V5 R1 was in pain. V5 stated she asked R1 where her pain was located and R1 took her right hand and pointed to R1's right leg. V5 stated she then went to get the nurse (identified as V3/LPN) and informed V3 R1 was complaining of pain. V5 stated V3 immediately followed V5 back to R1's room. V5 stated she observed V3 questioning R1 about what happened and observed V3 assessing R1. V5 stated she heard R1 tell V3 R1 was in pain. V5 stated she then left R1's room and resumed caring for her other assigned residents. V5 stated she later received a phone call from V2 (DON) inquiring about R1's knee and what happened during the time V5 was caring for R1. V5 stated she informed V2 she was not aware of what happened with R1's knee and only reported to V3 (LPN) what R1 had reported to V5. V5 stated R1 requires a two person assist when being transferred with a mechanical lift device. V5 stated the protocol for using the mechanical lift device is to always call another staff member to help transfer a resident who requires a mechanical lift device. V5 stated if a staff member operates the mechanical lift device without the assistance from another staff member while transferring a resident, the mechanical lift device can tilt over, and the resident could fall and injure themselves. V5 stated while operating the mechanical lift device, one staff member should be located at the back of the mechanical lift device and one person should be located in the front of the mechanical lift device. V5 stated this procedure helps to prevent resident injuries. On 09/12/2024 at 3:05PM, V6 (Staff Coordinator) stated she was made aware R1 was injured due to a transfer in the facility. V6 stated she was asked by V2 (DON) to contact V4 (CNA) via telephone to ask V4 to come into the facility to give a statement. V6 stated V4 told her V4 could not come to the 145977 Page 2 of 3 145977 09/13/2024 South Shore Rehabilitation 2425 East 71st Street Chicago, IL 60649

F 0689 Level of Harm - Actual harm Residents Affected - Few facility because V4 was informed V4 was taken off of the schedule and was under investigation because V4 transferred R1 alone without any staff assistance. V6 stated she then asked V4 if V4 transferred R1 improperly and V4 stated yes. V6 stated she continuously tried to text and call V4 for several days after the initial phone call but V4 never answered V6's calls or texts afterwards. V6 stated V4 never returned to the facility to follow up on V4's employment at the facility either. Nursing progress note dated 08/12/2024 at 3:35PM written by V3 (LPN) documents, Writer was called into R1's room, writer noted R1's right knee with swelling and pain. PRN pain medication given and tolerated. NP/Nurse practitioner is in the facility, new orders for X-ray of the right given. All orders noted and carried out. Nursing progress note dated 08/13/2024 at 10:29AM written by V3 (LPN) documents, X-ray company is in the facility to perform X-ray on R1's right knee. NP is also in the facility to assess R1. Nursing progress note dated 08/13/2024 at 3:29PM written by V3 (LPN) documents, X-ray results were relayed to NP, new orders were given to send R1 out to ER. Family was made aware of orders, POA/Power of Attorney stated she does not want R1 to go out to the emergency room, she does not want R1 to have to be sitting and waiting for long periods of time and they won't do anything. She stated she wants R1 to wait on her Dr. appointment. R1 has an outpatient Ortho appointment on 8-21-24 @8am. NP is aware of family wishes. Per facility reported incident dated 08/13/2024, R1 sustained a right knee fracture while at the facility. Facility witness statement dated 08/14/2024 written by V2 (DON) documents V4 informed V2 V4 transferred R1 from the bed to the chair without the use of the required mechanical lift devices. R1's X-ray report dated 08/13/2024 documents R1 has an acute fracture of the mid patella with 1cm separation of fracture fragments. Facility nursing schedule dated 08/10/2024 documents V4 (CNA) was assigned to the 2nd floor during the 10PM-6AM shift. Facility CNA assignment sheet dated 08/10/2024 documents V4 (CNA) was assigned to care for R1. R1's resident care card documents R1 requires the use of a mechanical lift device with two person assistance. R1's care plan dated 06/07/2022 documents in part, R1 requires assist with ADL'S related to Impaired Mobility. Transfer from bed to w/c and vice versa with use of Hoyer Lift x 2 staff. Facility policy undated, titled, Safe Lifting and Movement of Residents documents in part, Policy Statement: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses mechanical lifting devices for the lifting and movement of residents. 1. Mechanical lifting devices shall be used for any resident needing a two person assist. Except during an emergency situation or unavoidable circumstances, manual lifting is not permitted. 145977 Page 3 of 3