Health inspection·December 13, 2023

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 observation, interview and record review, the facility failed to utilize a gait belt while transferring a resident and failed to ensure that fall interventions were put into place for 2 of 15 residents (R116 and R21) reviewed for falls in the sample of 41. Findings include: 1. On 12/07/23 12:15 PM R116 was sitting in her wheelchair (w/c) in her bathroom after being assisted with toileting by V5 (Certified Nursing Assistant/CNA). V5 then pushed R116 in her w/c to her bedside and assisted her to stand and pivot and lay down in bed. V5 did not put a gait belt around R116 to transfer her. R116 stated she had two falls before coming to the facility and broke her back. She stated she hit her head both times. R116 stated they have told her not to transfer by herself without assist. R116's Resident Care Summary dated 12/1/23 documents R116 requires assist of 1-2 for toileting, assist of 1-2 for positioning, assist of 1-2 for transferring and assist of 1-2 for mobility with wheelchair assisted. It documents R116 is receiving Physical Therapy and Occupational Therapy. On 12/08/23 at 3:14 PM V2 (Director of Nursing/DON) stated if staff must lay hands on a resident to assist them to transfer from the toilet to the w/c or w/c to bed, they should use a gait belt during the transfer for resident safety. On 12/12/23 at 10:45 AM V5 (CNA) stated she should have used a gait belt when she transferred R116 from the toilet to her w/c and from her w/c to her bed because R116 can do really good when transferring on some days but can be weaker and more unsteady on other days. V5 stated that was a crazy day when she was observed not using the gait belt when she transferred R116 from the toilet to her w/c and then from the wheelchair to her bed, but she should have still used the gait belt during the transfer. 2. R21's Physician Order Sheet (POS) dated December 2023 documents a diagnosis of Neurocognitive disorder with Lewy bodies, Dementia in other disease classified elsewhere, anxiety, unspecific severity with psych disturbances, GERD (Gastroesophageal Reflux Disease) , paroxysmal A-fib (Atrial Fibrillation), spinal stenosis collapsed vertebra, hypothyroidism, overactive bladder, vitamin D deficiency, major depression disorder, hypertension, personal history of COVID, hypothyroidism, low back pain, and solitary pulmonary nodule. R21's Minimum Data Set (MDS) dated [DATE] document R21 was severely impaired for decision making of Page 1 of 2 146142 146142 12/13/2023 Meridian Village Care Center 27 Auerbach Place Glen Carbon, IL 62034

F 0689 activities of daily living (ADL). Level of Harm - Minimal harm or potential for actual harm R21's Care Plan document R21 has ADL selfcare deficit related to decreased mobility and muscle weakness (one assist-two assist). The Care Plan Goal documents that (R21) will not sustain a fall related injury by utilizing fall precautions through next review. Residents Affected - Few The Fall Log provided by the facility on 12/7/2023 document R21 had 5 falls that were documented as occurring on 3/20/2023, 6/13/2023, 6/29/2023, 9/9/2023, and 9/17/2023. R21's Fall Report dated 3/20/2023 at 11:30 PM, documents, Resident observed on roommate's fall mat sitting on buttocks. ROM (range of motion) in normal limits for resident. No injuries noted. Describe immediate intervention listed: VS (vital signs), neuro checks and skin assessment. No other intervention was documented for R21. R21's Care Plan does not document any interventions for the fall on 3/20/2023. R21's Clinical Notes dated 3/20/2023 at 11:39 PM documents Observed on fall mat. R21's Fall Report dated 6/13/2023 at 1:40 AM, documents, Resident caught walking out of bedroom independently. Staff tried to redirect, and he became aggressive with staff and lost his balance and fell. Describe immediate intervention, Body assessment completed, and vital signs taken and helped back to bed. No other intervention was documented for this fall on 6/13/2023. R21's Clinical Notes dated 6/13/2023 at 1:44 AM documents, Resident caught walking out of bedroom independently. Staff tried to redirect, and he became aggressive with staff resident tried to yank back and fell to floor. R21's Care Plan does not document any fall intervention for R21 for the fall on 6/13/2023. On 12/13/2023 at 10:45 AM, V2 (Administrator) stated she would expect a new intervention to be initiated after every fall. The facility's policy, Falls and Fall Risk, revised 9/14/22 documents, Based on previous evaluations 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. Fall Prevention-Potential Interventions: Staff Education: Gait belt for transfers and ambulation, as appropriate. The facility's policy, Safe Lifting and Movement of Residents, revised 10/14/19, documents, In order to protect the residents, and to promote quality care, this community uses appropriate techniques and devices to lift and move residents. 4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, slide boards) and mechanical lifting devices. 146142 Page 2 of 2