F0689

G

Failure to Follow Two-Person Assist Requirements During Care Resulting in Resident Falls

Burbank, Illinois Survey Completed on 01-11-2026

Penalty

11 days payment denial

Summary

The deficiency involves the facility’s failure to provide adequate supervision and assistance during care in accordance with residents’ assessed needs and care plans, resulting in falls for two residents. The first resident (R1), an older adult with morbid obesity, lack of coordination, COPD, dementia, and hypertension, had an MDS dated 09/15/2025 indicating moderate cognitive impairment (BIMS 10/15) and dependence on staff for toileting hygiene, rolling, showering, dressing, and bed mobility, requiring the assistance of two or more helpers. On the evening of the incident, a CNA (V8) provided routine evening care to R1 alone, positioning the resident on her side. During this care, V8 observed R1’s leg moving downward and R1 sliding toward the edge of the bed, ultimately sliding to the floor into a seated position while holding the side rail.

Following the fall, an LPN (V4) responded to the room after being called and found R1 on the floor, not very responsive. V4 instructed one nursing assistant to call 911 and another to call the supervisor, assessed R1 on the floor and again after R1 was assisted back to bed with a mechanical lift, and noted that R1’s vital signs were lower than initially but that R1 was still breathing. EMS arrived, and when V4 returned to the room after printing paperwork, paramedics had initiated CPR, which V4 estimated lasted about 20 minutes before R1 was pronounced deceased. R1’s roommate recalled that staff helped R1 right away after the fall, and a family member reported having spoken with R1 earlier that evening while staff were in the room assisting, later being called to the facility after the event. The family member stated that R1 fell because only one CNA provided care when two were required and expressed questions about how R1 was assessed and when CPR was initiated. The facility was awaiting the coroner’s report, and the relationship between the fall and R1’s death could not be determined at the time of review.

The second resident (R2), an older adult with hypoxic ischemic encephalopathy, respiratory failure on a ventilator/tracheostomy, acute embolism and thrombosis of the femoral vein, thoracic aortic aneurysm, bowel and bladder incontinence, and receiving enteral nutrition, had an MDS indicating severely impaired decision-making and dependence on staff for toileting hygiene, rolling, showering, oral care, dressing, and bed mobility, requiring the assistance of two or more helpers. During rounds, a CNA (V13) provided peri-care to R2 alone, with R2 positioned at the edge of the bed. V13 reported that when turning R2, the resident slid out of bed toward the door, despite the care plan requiring two-person assistance; V13 stated that R2 required two-person assist but that she believed she could handle the care by herself and had been doing so. Nursing notes by an RN (V12) documented that R2 was found lying on his back on the floor next to the bed with a laceration to the left scalp with active bleeding and a scratch on the left side of the neck. R2 was treated at the facility for bleeding control and then transferred via 911 to a local hospital, where records showed a scalp laceration requiring three staples and a left shoulder contusion. The Restorative Director and the DON acknowledged that both R1 and R2 required two-person assistance during care based on MDS assessments, but each was being cared for by a single CNA at the time of their falls, contrary to their care plans and the facility’s fall prevention policy.