Health inspection·October 14, 2022

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide a safe transfer and failed to avoid storing medical equipment in resident areas to prevent falls for 2 of 16 residents (R2, R20) reviewed for falls in the sample of 34. Findings include: 1. R2's Face Sheet, run date 10/14/2022, documents R2' diagnoses as Alzheimer's disease, unspecified, Age-related osteoporosis without current pathological fracture, age-related physical debility, history of falling, Other secondary osteonecrosis, right femur, Unspecified osteoarthritis, Parkinson's disease and syncope and collapse. R2's Minimum Data Set (MDS) undated documents R2 has severely impaired cognition, requires Extensive Assistance of 2 for transfers and toileting, is not steady and is only able to stabilize with staff assistance when moving on and off the toilet and surface to surface, and is occasionally incontinent with both bowel and bladder. R2's MDS has no documentation of admission history of falls and documents R2 has had one fall since admission. R2's Care Plan dated 6/30/2020 documents R2 is at risk for falls/injury as evidenced by history of falls, cognitive status/behavior, vision status, continence, mobility, and balance. Interventions include toileting before and after meals related to fall 2/9/22; assess wheelchair safety due to fall on 3/10/22 and staff education related to fall on 9/14/22. R2's Fall Investigation dated 9/14/22 documents CNA (Certified Nursing Assistant) transferring R2 using sit to stand, mechanical lift. Staff stated one side of the harness clip popped off of hook, one side remained hooked, and the resident remained harnessed in. Lift arm lowered , R2 lowered to the floor. R2 assessed for injury and then transferred to sitting chair via staff assist. R2 then transferred to toilet with sit to stand after this nurse inspected harness and clips for defectiveness or breakage. This nurse remained present for the completion of transfer. Transfer completed without further incident. Describe Immediate Interventions Taken after Event Occurred: Staff educated on ensuring harness clips are securely in place. Post Fall Huddle-Mini Root Cause Analysis: Improper use of Assistive Device. Possible Interventions to Minimize Future Falls and Injuries: staff education. On 10/13/22 at 2:25 PM, V8 (CNA) states she was the one transferring R2. V8 states, I was certain that I had attached the sling properly, but it just popped off. Anytime you operate a mechanical Page 1 of 3 146142 146142 10/14/2022 Meridian Village Care Center 27 Auerbach Place Glen Carbon, IL 62034

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few lift, it's a 2 person assist. At no time did R2 fall, the other person and I guided R2 and prevented her from hitting the floor. This has been traumatic for me, as well because I would never intentionally do anything to place my residents in harm's way. I did receive in-service training on all mechanical lifts. On 10/13/22 at 1:30 PM, V9 (Licensed Practical Nurse/LPN), states she (V9) did not recall the fall involving R2. V9 could not remember any details but if a fall occurs because of staff error facility does require in-service training in-service is similar to new hire training and do require return demonstrations. No major problems have been reported with the mechanical lifts that required contacting the company. Both types of mechanical lifts are checked before each resident use by staff and monthly by maintenance. R2's Physical Therapy assessment dated [DATE] documents Recommend patient to use sit/stand lift with staff for safety. The Facility Policy Using a Mechanical Lift origination date 4/1/2008; review date 5/6/19 documents Policy statement : The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lift device. It is not a substitute for manufacturing training or instructions. - Before resident is lifted, double check the security of the sling attachment. 2. R20's Face Sheet, run date 10/14/2022, documents pertinent diagnoses as Dementia in other diseases classified elsewhere with behavioral disturbances and Parkinson's disease. R20's MDS dated documents R20 is moderately impaired-cognitive for daily decision-making , making poor decision, cries and supervision required. R20 is Independent in bed mobility, transfer, walk in room, eating, toilet and personal hygiene; help only in walking in room, locomotion on unit and dressing. Moving from seated to standing position- steady at all times, in walking, turning around and surface to surface transfernot steady but able to stabilize without staff assistance. R20 does not use a mobility assistive device. Toileting and putting on and taking off footwear, R20 completes the activity (helper only) assists prior to or following the activity. R20 is frequently incontinent of urine and occasionally incontinent of bowel. R20 has adequate hearing and vision. R20's Fall Investigation dated 2/9/22 documents R20 had a witnessed fall in the bathroom, took self to bathroom, no socks or shoes on feet, upon exiting bathroom, R20 bumped into roommate's (geriatric reclining) chair and fell to her (R20) knees. CNA walking past room at time of incident and witnessed incident. CNA states she (R20) did not hit her head and got herself up off the floor before she could be assessed. R20 suffered a small skin tear to right dorsal-lateral, no other injuries noted. Range of Motion (ROM) within normal limits (WNL). Possible Interventions to Minimize Future Falls and Injuries: environmental safety review, appropriate footwear, assess for pain, non-skid socks, (geriatric reclining) chair to be moved in hall at nighttime. R20's Fall Investigation dated 7/17/22 documents R20 was walking in hallway and tripped over mechanical lift in hallway. R20 denied pain, Range of Motion (ROM) within normal limits (WNL). Neuro started per policy. Possible Intervention to Minimize Future Falls and Injuries: Environmental safety review, appropriate footwear, new shoes, educated staff on putting mechanical lift away. R20's Care Plan dated 3/3/21 documents Care area of Falls. R20 is at risk for falls/injury as 146142 Page 2 of 3 146142 10/14/2022 Meridian Village Care Center 27 Auerbach Place Glen Carbon, IL 62034

F 0689 evidenced by history of falls, cognitive status/behavior, vision status, continence mobility and balance. Level of Harm - Minimal harm or potential for actual harm Progressive interventions include roommate's (geriatric reclining) chair to be removed into hallway at night due to R20's fidgetiness, related to fall dated 2/9/22; remind R20 and reinforce safety awareness, lock brakes on bed, chair, etc. before transferring, educate/remind R20 and/or family to request assistance for all ambulation and transfers; non-skid socks and appropriate footwear for the fall dated 7/17/22. Labs requested, apply shoe to other foot as related to fall on 7/30/22; R20 to wear grip socks at all times, related to shuffling gait in shoes, related to fall on 8/22/22. Residents Affected - Few On 10/14/22 at 11:00 AM, V1 (Administrator) states residents are assessed by therapy for decline or improvement before using any mechanical lifts. If there is an adverse event, like a fall the nurse on duty will begin the process, will involve staff to determine cause of adverse event and then the management team will evaluate and educate to prevent future adverse events. Our lifts are relatively new, and all maintenance is completed by that company. There have not been any major problems with the lifts. The lifts are not left in the room we have restructured the rooms and included a storage space to accommodate the lifts to prevent blocking of the entrance. R20 has shuffling gait problem and we try to keep things out of the way to prevent her falling. The (geriatric reclining) chair was her (R20's) roommate's chair. It was agreed upon by all parties involved that the chair would be placed outside of the room at the end of evening and all residents were in bed. The Facility policy Management of Fall Risk origination date 1/22/17, revision and review date 9/14/22, documents Policy Statement: Based on previous evaluation and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. 146142 Page 3 of 3