F0689

G

Failure to Supervise High-Risk Residents Resulting in Falls and Fractures

Yorkville, Illinois Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and a hazard‑free environment for residents at high risk for falls, resulting in falls with fractures for two residents. One resident (R1), who had diagnoses including CHF, shortness of breath, Type 2 DM, morbid obesity, anxiety disorder, and a prior wedge compression fracture of the first lumbar vertebra, required one‑person assistance with bathing and had a care plan noting a history of multiple falls. On the day of his fall, R1 went to the shower room in his wheelchair with clean clothes. He reported that while in the bathroom he finished and told a CNA (V3) he was ready to get up, but she told him to wait; he stated he had already been sitting for 25 minutes and did not want to wait, so he attempted to transfer himself to his wheelchair and fell. R1 stated that V3 was on the phone, that she and another CNA (V20) helped him up, and that V3 did not report the fall to the nurse.

Nursing and CNA statements and documentation show inconsistent but related accounts of the same event, all indicating that R1 was not properly supervised in the shower room and that the fall was not promptly reported to nursing for assessment. The LPN (V4) on duty saw R1 pass the nurses’ station with clean clothes, later saw the shower room call light and confirmed V3 was in the room with R1, and then saw V3 wheel R1 back to his room. R1 then told V4 he had fallen in the shower room, had severe back pain, and wanted to go to the hospital. V4 documented that V3 had not informed him of the fall and that when questioned later, V3 said she was going to tell him and that she had told R1 not to remove his rubber shoes. V3’s own written statement said she told R1 not to take his shoes off in the shower and that he stood up and slipped; another CNA (V20) stated that V3 had told R1 to go to the shower room alone, that she knew he could not shower independently, and that V3 later asked her to help get him up after he fell. The facility’s incident report and hospital records confirm that R1 slipped and fell in the shower, was not with a CNA at the time of the fall per the final investigation addendum, and was later found to have an acute compression fracture of L1.

The second resident (R3) also experienced multiple falls with serious injuries in the context of high fall risk and inadequate supervision. R3 had diagnoses including vascular dementia, major depressive disorder, Type 2 DM, and right knee pain, and his care plan identified him as at risk for falls due to vascular dementia, with interventions including chair and bed alarms and keeping him in visual range of floor staff. His records show a fall resulting in a right tibia fracture, two additional falls on the same later date that led to two separate ED visits and rib fractures, and another fall on a subsequent date where he was found on the floor on his left side outside his room, reporting pain to his back, left shoulder, and left hip. The facility’s serious injury incident report for that later fall states that the final investigation determined he sustained a left femur fracture. The administrator and an RN both described R3 as very impulsive, with dementia, and noted that he needed 1:1 support and that staff tried to keep him with someone or provide 1:1 “as much as they could,” but they were not able to provide continuous 1:1 care. Despite his repeated falls, documented cognitive impairment, and identified need for close supervision, he continued to experience falls with fractures, indicating that the planned interventions and supervision were not effectively implemented to prevent these events.

The facility’s own falls management policy requires that residents identified as high risk have fall prevention addressed on the plan of care and that when a resident falls, reports falling, or is suspected of falling, staff must assess for injury, provide treatment, and document in the EHR. In R1’s case, the resident was left alone in the shower room despite requiring assistance with bathing and having a history of falls, and the CNAs who assisted him from the floor did not immediately notify the nurse, contrary to policy. In R3’s case, although his care plan called for alarms and keeping him within visual range, he was repeatedly found on the floor after unwitnessed falls, including outside his room, despite staff awareness of his impulsivity and dementia. These actions and inactions demonstrate a failure to provide adequate supervision and to consistently follow the facility’s fall prevention and post‑fall assessment procedures for residents at high risk for falls.