F0689

G

Failure to Follow Fall Policy, Use Gait Belt, and Perform Post-Fall Assessment After Shower Transfer Incident

Alton, Illinois Survey Completed on 01-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its fall management and gait belt policies for a cognitively impaired resident identified as being at risk for falls and receiving apixaban for atrial fibrillation. The resident’s care plan required assistance with transfers and ambulation and specified maintaining appropriate bed height and call light access, but did not document whether a gait belt should be used, the number of staff required, or the mode of transfer. On the evening in question, a CNA requested assistance from an RN to transfer the resident from a shower chair to a wheelchair because the resident’s knees were buckling and she was weak. During the transfer, the CNA stood the resident up to hold the grab bar, moved the shower chair away, and the resident’s knees buckled; the CNA and RN then lowered the resident to the floor without a gait belt in use, despite the RN later acknowledging that a gait belt probably should have been used due to the resident’s weakness.

Following this event, the RN observed a small amount of blood on the resident’s mouth and noted that the resident’s dentures were broken, but reported she did not see or hear the resident hit her mouth or head on the rail and therefore did not consider the incident a fall. The CNA later told the RN, about an hour afterward, that the resident’s face had hit the handrail, but the RN still did not notify the provider, did not complete a post-fall assessment, did not obtain vital signs, and did not perform neurological checks, despite facility policy requiring a post-fall evaluation and neuro checks for any fall in which the head was struck. There was no documentation in the electronic medical record on the date of the shower incident regarding a fall, being lowered to the floor, or the resident’s injuries, and no SBAR or post-fall assessment was completed at that time.

Approximately 12 hours after the incident, an LPN coming on day shift received report that the resident had fallen in the shower, assessed the resident, and noted dried blood on the lip and complaints of significant mouth pain. The LPN immediately notified the nurse practitioner, who ordered transfer to the ER for evaluation and treatment. Emergency department records documented that the resident presented for evaluation of a fall the previous day with head and facial impact, jaw tenderness and pain on movement, lip abrasion, and bruising to the right upper extremity, and underwent EKG, blood work, head CT, and chest x-ray. The administrator and nurse practitioner both stated there was no documentation of the shower fall or post-fall assessments in the medical record, that the resident was not promptly sent to the ER despite being on a blood thinner, and that staff were expected to follow the facility’s fall and gait belt policies, including treating being lowered to the floor as a fall and using gait belts during transfers.