Avantara Chicago Ridge

F 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

in there after lunch, and he was on the floor on the left side of bed. He was sitting up on the floor. I asked him and he did not respond. He was still alert but not verbally responsive. I called the nurse. He was on a low air loss mattress; his left hand was in the rail.V5 (RN, Agency) was also interviewed regarding Resident R1 on [DATE REDACTED] at 12:52PM. V5 stated, On [DATE REDACTED] morning shift, the CNA (V4) reported to me he was sitting on the floor. When I saw him, his arm was still holding the side rail. His head was slumped to the side of left side rail. I did head to toe assessment, he was not verbally talking, he can open his eyes a bit but not saying anything. He was sitting on the floor. I don't know if he slid down. He wouldn't keep his eyes open when I call his name. I called paramedics. He kept on grunting and kept closing his eyes. I noticed mild swelling on

the left side of his face, by the eyes. There was no laceration, no issues with his eyes. He was not verbally responsive, his mental status is my focus, that is why I called emergency. I saw him on the floor and my first thing is to call paramedics because he was not responding.According to ambulance report dated [DATE REDACTED], paramedics found patient (Resident R1) lying in bed, alert to painful stimuli only. Nursing staff stated that they were in

the room, left for about 5-10 minutes and when they came back, they found patient (Resident R1) half on the floor with his arm wrapped around the side rail of bed. Staff stated the patient (Resident R1) normally alert, oriented to self, time, place and situation and able to hold conversations. Patient (Resident R1) was spitting up mucous and bruising was noted to the left side of his face and his left eye pupil was in a slit and rotated. No other injuries were noted.Emergency department attending physician notes dated [DATE REDACTED] recorded Resident R1 has bruising to the left side of head; and left eye is irregularly shaped, not circular, linear, not reactive.On [DATE REDACTED] at 12:19 PM, V2 was asked on what was the cause of Resident R1's fall. V2 verbalized, Based on what I received there was no injury related to the fall. He had a fall; he was observed on the floor by the CNA who reported to the nurse. And upon the nurse entering the room, she noted him not be responding. I did his fall investigation I have witness statements only, but there was no injury noted upon assessment prior to sending out to the hospital. The nurse said she did not know any swelling, nothing pretty much. Facility presented two witness statements related to Resident R1's fall on [DATE REDACTED], as follows:V5 was asked about representative notification; any bruising; hospital endorsement; last time Resident R1 was seen and how long Resident R1 was transferred to the hospital. V4 was asked when was the last time Resident R1 was seen and his condition; and if she (V4) was the staff who observed Resident R1 on the floor.There was no specific investigation related to the cause of his (Resident R1) fall and how he fell. On [DATE REDACTED] at 10:38 AM, V10 (Physician) was interviewed regarding Resident R1 and Resident R5. V10 stated, Resident R5 has dementia, had traumatic subdural hematoma and has history of syncope and collapse. On [DATE REDACTED], I was informed that she had a fall. She was sent to the hospital. Resident R1 has multiple significant medical issues. Alert, he has cancer of the head and neck and was getting treatment from the hospital. He has cancer of the prostate, chronic kidney disease and multiple several medical issues: chronic or acute. He is getting blood thinners. On [DATE REDACTED], I was notified that he had a change of condition, so he was sent out to the hospital, and he had a fall. The assumption was he had a fall, and he needs to go to emergency room. Staff should make all efforts to prevent falls. The goal is to prevent falls. Fall interventions should be patient centered. Facility's policy titled Fall Occurrence dated [DATE REDACTED] stated in part but not limited to the following:Policy Statement: It is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions are reevaluated and revised as necessary.

Procedure:5. The Falls Coordinator will review the incident report and may conduct his/her own fall investigation to determine the reasonable cause of fall.

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