WESTMONT CONVALESCENT CENTER
Facility I.D. Number: 0030015
6501 S. Cass
Westmont, Illinois 60559
Date of Survey: 11/05/1999
Annual Licensure Survey
The facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the resident, in accordance with each resident's comprehensive assessment and plan of care. Adequate and properly supervised nursing care and personal care shall be provided to each resident to meet the total nursing and personal care needs of the resident.
All nursing personnel shall assist and encourage residents with ambulation and safe transfer activities as often as necessary in an effort to help them retain or maintain their highest practicable level of functioning.
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.
These regulations are not met as evidenced by:
Based on record review and staff and resident interview the facility staff failed to follow safe practices in transferring 2 sampled residents resulting in injuries to the residents.
Findings include:
1) On 11/02/1999 R8 informed surveyor that on 11/01/1999 while she was being transferred to the wheelchair a staff member dropped her to the floor. R8 stated the staff member then went to get help from another staff member and the two staff transferred her into the chair. R8 complained of discomfort on the left side of her body and stated a staff member told her she had a bruise on the left hip.
R8 is non ambulatory and needs extensive assist in transferring. R8's plan of care called for two staff to assist in transferring R8.
Review of record did not document that an incident had occurred with R8. Administrative staff was informed of R8's allegations and proceeded to investigate the incident. The investigation resulted in a staff member admitting the event occurred and that the staff member failed to inform the nurse on duty about it.
2) R10 was admitted on 08/02/1994 with diagnoses which includes, old CVA, arthritis, and anemia. R10 is alert and verbally responsible. She has no cognitive deficit.
During initial tour of 11/02/1999, R10 was observed sitting in a wheelchair with a long leg cast to left leg.
Review of medical record and interview with administrative nursing staff revealed that R10 received a compound fracture to her left leg on 08/19/1999, during a pivot transfer from bed to wheelchair by two direct care staff.
Documentation from medical record, MDS assessment of 07/15/1999, and care plan revealed the R10 is totally dependent on staff for transfers, and due to her excessive weight of 214 lbs. R10 should be transferred by Hoyer lift.
On 08/19/1999, two direct care staff performed a two man pivot transfer on R10 instead of using the Hoyer lift. The care plan identified the Hoyer lift as the proper way to transfer R10.
During this transfer, R10 fell to floor with a resultant compound fracture. Correction of this fracture required surgery with open reduction and internal fixation of the fractured leg.