Health inspection·May 31, 2024

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 interview and record review, the facility failed to train staff on how to properly use equipment to prevent a fall for one resident (R1) of three residents reviewed for falls in a sample of three. Findings include: The Falls and Fall Risk policy, dated 12/2007, 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. The Manufacturers User Manual for Alternating Pressure and Low Air Loss Mattress documents, Read all instructions before using. This manual should be used for the initial setup of the system and for reference purposes. Operating Instructions 10. Press the Static button to set it in static mode, and the Static indicator will come on. The static mode will be started within approximately 6 (six) minutes. Press the Static button again to switch back to alternating mode. Note! In the static mode, the mattress provides a firm surface that makes it easier for the patient to transfer or reposition. The Know the settings of the Low Air Loss Mattress (not dated), documents, if the Static button remains depressed and is on, the mattress is as firm as a regular mattress. Use this button to transfer patients in/out of bed. R1's current computerized medical record, documents R1 is an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Cerebral Infarction, Paroxysmal Atrial Fibrillation, Systolic (Congestive) Heart Failure, Essential (Primary) Hypertension, Weakness, Epilepsy, and Anxiety Disorder. R1's MDS (Minimum Data Set), dated 4/25/24, documents a BIMS (Brief Interview for Mental Status) Score of 3/15, indicating severe mental impairment. R1 requires substantial help for toileting, is frequently incontinent of bowel/bladder, and is dependent on staff for transfers. V4's Witness Interview Form, dated 5/22/24 at 10:48 AM, documents R1 was hollering out for help while in his wheelchair. V4/CNA and V5/CNA transferred R1 with the (mechanical lift) and laid R1 down. V4 stayed by the bedside, R1 was lying on his right side in bed with his face towards V4. R1 then started to go over the edge. V4 could not catch R1. V5's Witness Interview Form, dated 5/22/24 at 12:00 PM, documents V5 was in the room with V4, and they were going to provide incontinent care for R1. V5 went to the bathroom to get some wet cloths Page 1 of 3 146151 146151 05/31/2024 Clayberg, The 625 East Monroe Street Cuba, IL 61427

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and V4 was next to the bed by R1. While in the bathroom V5 heard R1 and V4 start yelling for help. V5 did not witness R1 roll out of bed. R1's Witnessed Fall Report, dated 5/22/24 at 11:33 AM, documents V15/Registered Nurse was called to R1's room by a CNA (Certified Nursing Assistant). R1 was lying beside the bed on his left side. R1 stated he fell out of bed. R1 had a skin tear to his left elbow. An intervention was put in place to push the static button on the bed that will equalize the air in the mattress before turning R1. Other info (R1) just received bed from hospice day prior. The Hospice Nurse (V6) informed staff that the static button on bed should be pushed when transferring or turning (R1) to level out mattress. (V6) stated that the air in the mattress was probably displaced and aided in (R1's) fall. R1's Incident Note, dated 5/22/24 at 1:21 PM, documents V15 was called to R1's room. R1 was lying beside the bed on his left side. R1 was assessed and had a skin tear to the left elbow. The intervention is when staff are turning R1, push the static button on the bed and that will equalize the air in the mattress. R1's Care Plan documents R1 is at risk for falls related to deconditioning, weakness, and impaired mobility. Staff will use the static button when positioning/turning R1 in bed. Date Initiated: 05/24/2024. After R1's fall on 5/22/24. On 5/30/24 at 8:38 AM, V1/Administrator stated R1 was given a new air mattress from Hospice. There were two CNAs in the room that were going to change R1. One of the CNA's went into the bathroom to get some washcloths and the other was still by R1's bed. The mattress shifted and R1 rolled out of bed on the side by the CNA. On 5/30/24 at 9:00 AM, V2/Director of Nursing/DON stated V4/Certified Nursing Assistant/CNA was next to R1's bed providing care for R1 when R1 fell out of bed. R1 had gotten a new air mattress the night before. The mattress was set up, but there were no instructions left with the mattress. V2 talked with V6/Hospice Nurse and found out there is a button that should be pushed to stabilize the bed. On 5/30/24 at 1:16 PM, V4/CNA stated she was going to give incontinent care to R1 with V5. R1 was on his right side facing V4. V5 had gone to get some gloves and washcloths. Suddenly R1 rolled out of bed. V4 does not know how R1 rolled out of bed it all happened quickly, and V4 could not hold R1. V4 was asked if the static button on the bed was on. V4 stated she did not know the static button should be on until V4 was in-serviced after R1 fell. On 5/30/24 at 12:23 PM, V5/CNA stated he had gone into the bathroom to get some washcloths and gloves. V4 was next to R1's bed. V5 then heard yelling and R1 had fallen out of bed. R1 had just got a new mattress the night before, and V5 did not know that the static button needed to be turned on before providing care for R1. Training on using the static button was not done until after R1 had rolled out of bed. V5 also stated, I try to do a good job and would like to know how I should do my job, so an accident doesn't happen. On 5/30/24 at 11:46 AM, V6/Hospice Nurse stated when R1 started on Hospice, he was given a low air loss mattress. There is a company that hospice has deliver the mattress, and they are to give training to someone at the facility on how to use it. It is important the static button is turned on any time staff is trying to move the resident in bed. Otherwise, the mattress will continue to have the air shift. If it is not on static the mattress is constantly moving. I was told that a couple of CNAs were providing care for (R1), and one went to get supplies. The other CNA could not hold (R1), and 146151 Page 2 of 3 146151 05/31/2024 Clayberg, The 625 East Monroe Street Cuba, IL 61427

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few he rolled out of bed. I offered to have an in-service provided for them (the facility). (V2/DON) stated that they (the facility) would do an in-service. On 5/30/24 at 4:44 PM, V11/ Equipment Manager stated the air mattress was delivered on 5/21/24. V11 talked with V14/Equipment Delivery Driver, and V14 stated after he did the setup for the mattress, V14 showed staff that were in the room how the equipment worked. V11 also stated the static button should be turned on anytime care is being provided to the resident in bed. This would include a dressing change, repositioning, and incontinent care. Once the static button is turned on, it takes five to six minutes for the mattress to get firm. On 5/30/24 at 6:02 PM, V13/CNA stated she was in the room when V14/Equipment Delivery Driver set R1's air mattress up. V14 explained to V13 to make sure the static button is on before doing care. There were no paper instructions given; it was all verbal. V13 also stated as soon as the static button is turned on, care can start. On 5/31/24 at 6:44 AM, V15/Registered Nurse stated she was called to R1's room and R1 was on the floor on his left side. V4 was on the same side of the bed where R1 fell, but V4 could not stop R1 from falling. V15 called V6/Hospice Nurse to report the fall and see if V6 wanted to come in to assess R1. While telling V6 what had happened, V6 told V15 about the static button that needed to be turned on during care to level the bed. V15 also stated, Hearing about the static button was news to me. I had no idea that it needed turned on. There was no booklet to explain what needed to be done. On 5/30/24 at 9:59 AM, V1/Administrator stated when V2/DON did the in-service, V2 read the Know the settings of the Low Air Loss Mattress to the staff. The facility does not have the manual for the mattress. V1 was not aware after the static button was turned on, it took six minutes before care should begin. 146151 Page 3 of 3