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Franklin Grove nursing home disputing state fine

Violation contributed to resident's death, investigators said

FRANKLIN GROVE – A nursing home here is contesting a $50,000 fine for a mechanical lift failure and other violations that state investigators say contributed to a resident's death.

The Illinois Department of Public Health fined Franklin Grove Living and Rehabilitation Center "for failure to ensure proper working mechanical equipment was being used to appropriately lift residents, and failure to record the problem so it would not happen again," it said in its quarterly report.

The 132-bed skilled-care facility at 502 N. State St. also was cited for a AA violation of the state Nursing Home Care Act, which occurs when a condition or an occurrence at a facility is the proximate cause of a resident's death.

Although it is cooperating with the state, the nursing home does not agree with all of the report's findings, and has requested a hearing to make its case, Administrator Jessica Rogers said Monday.

She declined to be specific, citing the ongoing investigation. The date of the hearing has not yet been set, and the fine has not been paid, she said.

"We try to give the best care that we can," Rogers added.

According to the report:

On June 10, a mechanical lift was being used to transfer a patient from a wheelchair to a bed, and the support loop to the sling holding her left leg broke.

She fell to the floor, breaking her left leg near her hip and her right leg near her knee. According to a physician where she was hospitalized, the broken bones caused her condition to deteriorate and contributed to her death 4 days later.

The subsequent investigation revealed that the loop was frayed: Fabric was missing, and threads were exposed.

The last time the lift slings were checked was about 3 weeks before the fall, a CNA supervisor said. There was no regular policy for checking the condition of lift slings, another staffer said.

One of the facility administrators told investigators had she seen the condition of the loop, she would have pulled the lift from the floor.

It was not the first time loops and slings had failed during a patient transfer. In a sampling of five patients reviewed for policies and procedures, investigators found:

One loop "just snapped" on the same patient shortly after her admittance April 27.

A sling loop broke on another patient who was being transferred from a bed to a wheelchair; she landed on the bed. About 2 weeks later, a sling broke on that same patient May 28 as she was being transferred from a wheelchair to a bed. Such transfers now make her nervous, her family told facility officials.

A lift sling loop broke on a third patient during a transfer from a wheelchair sometime around May 11; the loop closest to the sling snapped and he landed "a little sideways" in the wheelchair.

A sling was found to be torn behind the right shoulder of fourth patient, also being transferred from a wheelchair.

All but the incident involving the first patient were considered by staff to be "near-misses," because the patients weren't injured, and so were not documented. The facility's policy, however, is to document any incident "out of the norm," and so the incidents should have been documented.

Documentation was done for the first patient, but failed to show the cause of her fall was the broken loop.

A users manual for the slings warns that they should not be used if damaged, and states that slings should be examined each time they are laundered. "Bleached, torn cut, frayed or broken slings are unsafe and could result in injury. Discard immediately."

Facility staff since have inspected and replaced all full-lift slings and developed a policy for examining loops and slings after they are laundered. Laundry staff have been trained on what to look for, and charge aids will inspect the equipment daily.

In addition, the rules for documenting unusual occurrences have been strengthened.

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