PRAIRIE VILLAGE HEALTH CARE CENTER

Facility I.D. Number: 0042671
1024 W. Walnut
Jacksonville, Illinois 62650

Survey Date: 12/20/99

Incident Investigation

"A" VIOLATION(S):

All necessary precautions shall be taken to assure that the residents’ environment remains as free of accident hazards as possible. All nursing personnel shall evaluate residents to see that each resident receives adequate supervision and assistance to prevent accidents.

An owner, licensee, administrator, employee or agent of a facility shall not neglect a resident.

Based on interviews, record review, policy and resident inservice, review reveals that staff failed to provide assistive devices to prevent accidents on 1 of 2 residents on sample.

Findings include:

Review of R1's record and incident report dated 10/20/99 reveals that R1 was injured (fracture of humerus) (2 person physical assist/transfer). At 10:30 a.m., staff E3 and E4 verified during interview on 12/17/99 to surveyor that E3 and E4 did not use a gait belt during transfer of R1 from toilet to wheelchair. E3 and E4 state that R1's wheelchair brakes were locked, but yet the wheelchair rolled on right side of wheelchair causing E3 and E4 to have to pull R1 up and back into chair in order to keep R1 from falling onto floor. During this part of transfer, staff heard a snap. Staff reported this to charge nurse E5. E3 and E4 stated that E4 forgot gait belt (GB) that day so E3 and E4 were sharing GB. E3 and E4 indicated that GB had been left on the linen cart and this is why E3 and E4 did not use a GB during R1's transfer.

E1 indicated that E5 checked wheelchair brakes following incident and found them to be working correctly. E3 and E4 presented the possibility that wheelchair brakes must not have been on completely since wheelchair rolled.

R1's record revealed R1 DOB (7-9-09), admitted 12/28/95, with diagnosis currently of extended CVA (stroke) in part. X-ray of 10/30/99, at hospital, shows “comminuted fracture of the humerus with impaction and rotation of humeral head. Osteoarthritic changes are seen with diffuse osteopenia.”

Review of R1's most recent full assessment dated 9/2/99 reveals that R1 is extensive assist with transfers with one staff; balance while standing is poor and cannot do without physical support from staff; sitting balance is poor at times; she has functional limitations in range of motion (full loss) on right side. Care plan of R1 reveals R1 has history of CVA with hemiparesis, long and short term memory loss and moderately impaired cognitively, poor decisions, and the use of a gait belt to prevent injury. R1 requires supervision and assistance for mobility to a more safe position and proper alignment.

Review of facility policy/procedures reveals that staff are to use gait belts and lock wheelchairs during transfers.

E1 states E3 and E4 were verbally counseled and inservice given. E1 states this is first time for not using GB on E3 and E4. This was verified in E3 and E4's personnel files.