F0689

G

Failure to Control Environmental Hazards and Provide Required Supervision and Assistive Devices for High Fall-Risk Resident

South Holland, Illinois Survey Completed on 01-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain an environment free of accident hazards, provide adequate supervision, and ensure the availability and use of required assistive devices for a resident at high risk for falls. The resident is an elderly female with diagnoses including unspecified dementia with behavioral disturbance, peripheral vascular disease, hypertension, gait and mobility abnormalities, anxiety disorder, bilateral hip osteoarthritis, and vitamin deficiencies. Her MDS shows a BIMS score of 3, indicating severe cognitive impairment, and section GG indicates she requires partial/moderate assistance for sit-to-stand and bed-to-chair transfers and uses a manual wheelchair for mobility. A fall risk assessment score of 13 identifies her as high risk for falls, and her care plan calls for a restorative walking program with adaptive equipment as needed (e.g., wheelchair, walker, gait belt, cane), appropriate footwear, staff assistance with ambulation at the level required, and reminders not to ambulate without assistance.

On multiple observations by the surveyor, the resident was seen in the day room watching TV without any mobility device in her immediate vicinity and without appropriate footwear. On one occasion she was wearing regular socks and no shoes; on another, she had a regular sock on one foot and the other foot was bare. Her bed was observed in the low and locked position with a fall mat on one side, but no mobility devices were present in her room. The resident reported remembering that she fell and hurt herself but was unable to provide details due to disorientation and forgetfulness. Staff interviews revealed inconsistent understanding of her fall risk and required level of assistance. One CNA stated the resident was able to walk independently without assistive devices, freely walked around the unit, and was not a fall risk resident, despite also reporting that the resident required total assistance with ADLs and sometimes two-person assist when agitated, and that she would try to get out of bed unassisted.

The fall event occurred when the resident was following a CNA into her room while the CNA was assisting the roommate in the bathroom with the door closed. The CNA heard the resident say “Ouch,” then found her sitting on the floor with her back against the roommate’s bed, which had shifted because it was not locked. The CNA reported that she did not know who left the bed unlocked. An RN responded, assessed the resident, and documented that vital signs, neurological assessment, and pain assessment were within normal limits, and the resident initially denied pain. The resident was assisted to a wheelchair and placed in the day room. Later that day, another nurse noted the resident refused dinner and complained of pain in both legs; on further attempts to transfer her to bed, the resident was unable to stand, was in significant pain, and required pain medication and hospice assessment. The resident was subsequently sent to the hospital, where imaging showed a subcapital fracture of the right femoral neck with slight impaction, and she underwent right hip ORIF. The attending physician stated the fracture appeared to be fall-related and that the resident was considered a high fall risk, and also indicated that if a bed was unlocked it should have been locked and the resident should have been wearing non-slip footwear.

Staff interviews further demonstrated conflicting assessments of the resident’s fall risk and supervision needs. One RN described the resident as a fall risk but was unsure if she was high risk, and stated the resident was safe to walk around without assistance, while also acknowledging that the resident did not listen to staff, stood up whenever she wanted, and did not want to wear shoes. Another nurse stated the resident was not a fall risk before the fall but was afterward, and that the resident walked fine and did not use assistive devices. The DON/fall coordinator stated the resident was found on the floor after attempting to sit on a bed that was not locked and that the bed moved away from her, leading to the fall. The facility’s written policy on managing falls and fall risk requires staff to identify interventions related to specific risks and causes to prevent falls and minimize complications, but the interviews and observations showed that the resident’s high fall risk status, need for assistive devices, and need for appropriate footwear and supervision were not consistently implemented or adhered to at the time of the incident and subsequent observations.