F0689

G

Failure to Maintain Effective Fall Precautions and Supervision for High-Risk Residents

Woodstock, Illinois Survey Completed on 01-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain updated and effective fall precautions and supervision for residents at risk for falls, resulting in a fall with head injury for one resident and an inoperative fall-prevention device for another. One resident (R1), who had unspecified moderate dementia with behavioral disturbance, a history of falls, and was on hospice with documented severe tiredness, lethargy, worsening loss of strength, and impulsivity, was known by multiple staff to be a “big fall risk,” impulsive, and likely to get up without waiting for assistance if call lights were not answered promptly. Her care plan identified her as at risk for falls due to unsteady gait and balance, with interventions including staff monitoring while in the bathroom and observation for gait unsteadiness, but the Assistant DON acknowledged that bathroom-related fall interventions had not been updated despite R1’s recent decline and change in bathroom habits.

On the morning of 1/1/26, incident reports and staff statements show that a CNA (V5) responded to R1’s call light and screaming for help, found her in bed, and assisted her with a walker to the bathroom, placing her on the toilet and then leaving the room to attend to other tasks. Another CNA (V11) confirmed that R1 was clumsy with the walker and that both CNAs left the room to check on other residents while R1 remained on the toilet. A third CNA (V8) stated that R1 was using the bathroom and the CNA left her to answer another call light when the fall occurred. Staff interviews, including with the CNA supervisor (V4), multiple RNs (V6, V12, V14, V10), and the hospice RN (V16), consistently described R1 as clinically fragile, weak, lethargic, impulsive, and not willing to wait for help, and indicated that staff needed to stay close or in the room when she was in the bathroom. Despite this, R1 was left unattended on the toilet, and shortly thereafter staff found her on the bathroom floor on her left side with a head laceration and a puddle of blood under her head; she was described as nonresponsive, cyanotic, dusky, and with agonal breathing before being pronounced dead.

A second resident (R3), also identified as at risk for falls with a fall risk assessment score of 16 and a prior documented fall from bed, had a care plan intervention and physician order for a bed mobility alarm with instructions that staff ensure the alarm was in place and functioning properly every shift. During the survey, R3 was observed in bed with a bed alarm attached to the bed rail, but the alarm indicator lights were not on. When the CNA supervisor (V4) checked the device, the alarm cord was found on the floor under the bed and not plugged in; once plugged in, the alarm light flashed red, indicating it had previously been off. The facility’s Fall Risk Assessment and Prevention Program policy requires individualized interventions for residents at risk for falls and evidence of care plan review and update following each fall, but in R3’s case the ordered bed alarm was not in place and functioning as required at the time of observation.