F0689

D

Failure to Maintain Low-Bed Fall Precautions for High-Risk Residents

Beecher, Illinois Survey Completed on 01-27-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s failure to follow fall-prevention interventions for residents assessed as high risk for falls. One male resident with dementia, Parkinson’s disease, muscle wasting and atrophy, lack of coordination, and a history of repeat falls had a leaf symbol posted by his name outside his room, and his care card in the room closet listed “low bed” as a fall precaution. On multiple observations on January 23 and January 24, this resident was found lying in bed with the bed raised approximately two feet from the floor and not in the lowest position. The resident reported having had a fall at the facility. A CNA who had been assigned to this resident the previous day stated she was not aware of any specific fall precautions for him, despite the documented intervention of a low bed.

A second resident, a female with dementia, non-pathological and pathological fractures, disorders of bone density and structure, and repeated falls, also had a leaf symbol posted by her name outside her room. She was observed lying in bed sleeping with the bed raised approximately two feet from the floor and not in the lowest position, while she stated she was trying to get some rest. The Assistant DON/RN explained that fall risk assessments are completed on admission, quarterly, annually, as needed, and after new falls, and that the facility reviews all falls and prior interventions. She further stated that when fall precautions include a low bed, the bed should be in the lowest position when the resident is in bed, and that the beds can be lowered very close to the floor. Despite these stated practices and documented precautions, both high-risk residents were observed with beds not maintained in the low position as ordered.