Health inspection·January 27, 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 interview and record review, the facility failed to provide safe transfer with a full (mechanical) lift per care plan; failed to inform doctor of refusal in using the (mechanical) lift and failed to reassess for safe transfers for 1 (R1) of three residents (R1, R2, R3) reviewed for falls. This failure resulted to R1 sliding on the floor sustaining a fracture of the tibia/fibula. Findings include: R1's Facesheet indicates that R1 was admitted to the facility on [DATE] with diagnosis including but not limited to: Chronic Obstructive Pulmonary Disease, Emphysema, Chronic Respiratory Failure with Hypoxia and Hypercapnia, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Nondisplaced Oblique Fracture of the Shaft of Right Tibia, Venous Thrombosis and Embolism, Disorder of the Autonomic Nervous System, Irritable Bowel Syndrome, Pulmonary Blastomycosis, Urinary Tract Infection, Neurological Dysfunction of Bladder, Anxiety Disorder, Major Depressive Disorder, Agoraphobia with Panic Disorder, Other Cord Compression, Paraplegia, Essential Hypertension, Obesity, Obstructive Sleep Apnea, Gastroesophageal Reflux Disease without Esophagitis, Visual Hallucinations, Paranoid Disorder, and Age Related Osteoporosis without Pathologic Fracture. R1's Minimum Data Set with Assessment reference date of 12/31/2023 under Section C: Brief Interview for Mental Status (BIMS) documents a score of 13. (The BIMS assessment uses a points system that ranges from 0 to 15 points: 0 to 7 points suggests severe cognitive impairment. 8 to 12 points suggests moderate cognitive impairment. 13 to 15 points suggests that cognition is intact). On 1/26/2024 at 11:04 AM, R1 was observed in bed watching television. When asked what happened on 12/18/23, R1 stated, I had a fall. It happened after lunch, I wanted to get my hair cut. I haven't been out of bed for about 6 months, V5, the aide was helping to get up. V5 had me sitting at the edge of the bed and was standing to pivot when my legs buckled, and I ended up sitting on the floor. My right leg was under my body and my foot was flat and I heard the crack. I pulled out my foot slowly. V5 then called another CNA, V6. V6 picked me up and put me in the chair. From that point forward my leg was numb. In a case like that when I haven't been up for long time, we should have used the sit to stand. But I did get my hair cut that day. I fractured my shin. I gotta (sic) take responsibility for my stupidity, I should have known better but I wanted to get my hair cut. There's no one to blame for it. On 1/26/2024 at 1:22 PM, V5, Certified Nursing Assistant (CNA) stated, On 12/28/23, R1 had a hair appointment. She needs a (mechanical) lift for transfers but R1 refused to use the (mechanical) lift and she said she wanted to get up for the beauty shop. So, I got R1 ready, got R1 dressed and had R1 Page 1 of 3 145982 145982 01/27/2024 Citadel of Northbrook, The 3300 Milwaukee Ave. Northbrook, IL 60062

F 0689 Level of Harm - Actual harm Residents Affected - Few sit by the edge of the bed while I called another CNA for assistance. The R1 said she is dizzy and then she started sliding onto the floor. I held on to R1's gait belt and then she slid down on the floor. I informed V3, R1's nurse, that R1 refused to use the (mechanical) lift and V3 said that it's okay to transfer R1 with 2 person assist since she was refusing. When asked if V3 talked to R1 about dangers of not using the (mechanical) lift, V5 stated, V3 did not talk to R1 about it. V6, CNA, and V3 assisted R1 back to bed, with 3 person assist, we did not use the (mechanical) lift. On 1/26/2024 at 1:24 PM, R1 was interviewed again. R1 stated she did not refuse to use the (mechanical) lift and the (mechanical) lift was not offered for her to use. R1 stated, I have never used the (mechanical) lift. V5 did not have the Sit-to-Stand or (mechanical) Lift on 12/18/2023. We just didn't think to use it. I heard a crack on my bones when I fell on the floor. V5 and V6 assisted me to get up when I fell and put me back to the bed without using the (mechanical) lift. Progress Noted dated 12/18/2023 by V3, Registered Nurse documents in part: CNA (Certified Nursing Assistant) called NOD (Nurse on Duty) to informed (sic) that pt. (patient) slid to the floor during transfer (sic) resident to the wheelchair. NOD came to the resident room noted resident siting position on the floor next to the bed. Interview with V3, Registered Nurse, on 1/26/2023 at 1:20 pm was conducted. V3 stated, I was the nurse in charge of R1 on 12/18/2023. V5, Certified Nursing Assistant called me and informed me that R1 slid on the floor. V5 stated that she was getting R1 ready and had R1 sitting at the edge of the bed and R1 started slipping on the floor. I was then called to R1's room and observed R1 on the floor. I did a head-to-toe assessment, R1 said she was not in pain. V3 informed me then that (mechanical) lift was not used because R1 refused to sue the (mechanical) lift. When asked why her documentation on R1's progress notes stating that R1 refused to use the (mechanical) lift had a created date of 12/20/23, which was 2 days after the fall, V3 did not respond. assistance for all transfers. The said Care Plan does not address that R1 was refusing to use the (mechanical) lift. On 1/26/2024 at 1:30 PM, V2, Director of Nursing stated, When somebody refuses the (mechanical) lift, the staff needs to inform us so we can do an evaluation to assess for proper transfer. R1 sustained fracture of the tibia. When I called V7, Physician, V7 said the fracture was pathological, we didn't report it. I talked to V7 the following day, he said it's due to her co-morbidities, R1 has severe osteopenia. If it's pathological in nature, we don't send a report to the state reporting agency. V2 affirmed that tibial fracture is considered a serious injury. V2 stated there was no report submitted to the state surveying agency about this serious injury. Review of R1's medical records excludes documentation regarding any condition that would place R1 at risk for pathological fractures. On 1/26/2024 at 1:55 PM, V7, Physician, stated, For R1, we discussed the fall, and the discussion was that R1 was sitting on the side of the bed and was being assisted and slipped and did not really have any per se trauma. We reviewed R1's X-ray and showed severe Osteopenia and that certainly can contribute to a pathological fracture, in the absence of trauma. R1's severe osteopenia could have caused the fracture because I was informed that there was really no trauma to the extremity. I have been informed from time to time that R1 was refusing to use the body lift, but for this particular incident, I don't recall them informing me that she refused to use the (mechanical) lift on 12/18/23. On 1/26/2024 at 3:12 PM, V6, Certified Nursing Assistant (CNA) stated, I was in the room with V5. 145982 Page 2 of 3 145982 01/27/2024 Citadel of Northbrook, The 3300 Milwaukee Ave. Northbrook, IL 60062

F 0689 Level of Harm - Actual harm Residents Affected - Few When I got there, R1 was already on the floor. V5 prepared R1 for the transfer, and V5 said R1 slid on the floor. Then nurse checked R1, and R1 said she has no pain. So, the nurse, V6 and myself (sic) put her back to the bed, all 3 of us without using the (mechanical) lift. R1 said she wanted to go to the beauty shop, so all 3 of us transferred her to the wheelchair this time without using the (mechanical) lift so that she can go to the beauty shop. Review of R1's medical records excludes any documentation that R1 was reassessed for proper transfer techniques since R1 was allegedly refusing to use the (mechanical) lift. Review of medical records also exclude documentation that R1 was educated on the dangers of refusing to use the (mechanical) lift. V3, Registered Nurse, affirm that she was informed that R1 refused to use the (mechanical) lift after R1 slid on the floor. V3 documented on the progress notes with a created date of 12/20/2023, which is 2 days after the incident, that R1 refused to use the (mechanical) lift. R1's hospital records document under Xray Ankle Complete Minimum 3 Views, (Right) and Xray Tibia/Fibula, 2 Views (Right): Final Result, IMPRESSION: A minimally displaced oblique fracture involving distal tibia is noted with nondisplaced distal fibular diaphyseal fracture. Facility Policy titled Safe Lifting and Movement of Residents with a review date of July 2022 documents in part: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. POLICY INTERPRETATION and IMPLEMENTATION: 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include: a. Resident's preferences for assistance; b. Resident's mobility (degree of dependency); c. Resident's size; d. Weight-bearing ability; e. Cognitive status; f. Whether the resident is usually cooperative with staff; 145982 Page 3 of 3