Health inspection·October 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide safe transfer assistance. This applies to 1 resident (R1) of three reviewed for safe transfers. This failure resulted in R1 incurring a acute nondisplaced bimalleolar fracture and a nondisplaced oblique fracture of the distal fibula. Findings include: 1. R1's Medical diagnosis from the electronic record documents R1 as a [AGE] year old, with diagnoses to include Aphasia, Hemiplegia and Hemiparesis following a Cerebral Infarction. The Final Report to Illinois Department of Public Health, dated 10/17/2/2024, documents, On 10/11/2024, The resident was lowered to the ground after becoming weak during a transfer from her electric wheelchair to her bed via pivot transfer. A (mechanical lift) was used to lift the resident from the floor to the bed after a head to toe assessment revealed no obvious injury and subsequent assessments had not indicated any observable abnormalities to the right lower leg/ankle area. The resident later expressed pain to her right lower extremity during the early morning hours of 10/12/2024 and was sent to the ER (Emergency Room) for evaluation and sent back later that morning with no fractures or dislocation noted and norco for pain management as needed. The resident continued to have pain to the right leg with repositioning in bed and 10/14/2024 Dr ordered X-rays to the right hip/right femur/and right knee with no fracture of dislocation indicated. Dr. rounded on 10/15/2024 to evaluate the resident and ordered another set of X-rays to the right tibia/fibula, right ankle and right foot with the results sent to the facility on [DATE] with an acute non-displaced bimalleolar fracture and a non-displaced oblique fracture of the distal fibula. Dr. was notified and gave orders to send the resident back to the hospital for evaluation which confirmed the bimmalleolus fractures which appear to be minimally displaced and a soft cast was applied to the right lower extremity. A chronic fracture deformity of the right humeral neck and deformity of the right distal humerus which may require an elbow series if acute symptoms are present. A right arm sling was placed and resident was transferred back to the facility. Resident currently with Tylenol ordered for pain per family request. The Radiology Results Report for R1, dated 10/15/2024, documents under Findings: Right Tibia and Fibula~ An acute nondisplaced bimalleolar fracture is noted. The Radiology Report for R1, dated 10/16/2024, documents under impression Right Ankle~Displaced fractures through the lateral malleous and medial malleous. The care plan for R1 documents, The resident is risk for falls r/t (related to) Deconditioning, Gait/balance problems. Resident will have 2 cna assist to bed from scooter. Will use sit to stand or Page 1 of 2 146077 146077 10/26/2024 Serenity Estates at Morris 1223 Edgewater Morris, IL 60450

F 0689 Hoyer transfer to and from the bed to motorized wheel chair. Level of Harm - Actual harm On 10/24/2024 at 10:45 AM, V2, Director of Nursing, stated, That was (V8, CNA) first shift in the building. She will not be back to work here. The one person transfer was not appropriate. Residents Affected - Few On 10/24/2024 at 2:07 PM, V7, Licensed Practical Nurse, stated, None of us had never worked with (V8, Certified Nurse Aide/CNA) before. It was her first assignment from the staffing agency. At the beginning of the shift, we made it clear that if she needed anything to come and tell us. Everyone is more than willing to help with whatever you need. That why I couldn't believe what she did. She transferred (R1) by herself. The transfer is a two person transfer with (R1). (V8, CNA) told me she was doing a pivot transfer from the scooter to the bed when (R1's) leg buckled and (V8, CNA) lowered the resident to the floor. She should've asked us to help her with the transfer. On 10/25/2024 at 10:53 AM, V11, CNA, stated, (R1) is a two person assist for transfer, always. She's a sit to stand (mechanical) transfer. We always use a gait belt, the machine and two people. On 10/26/2024 at 2:22 PM, V4, Medical Director, stated, Yes I expect the staff to follow safe transfer procedure. That includes two to transfer for residents that require the support. I have already spoken to (V1, Administrator) regarding this. The policy titled Safe Resident Handling/Transfers, dated 10/01/2024, documents under #10. Two staff members must be utilized when transferring residents with a mechanical lift. 146077 Page 2 of 2