F0689

D

Failure to Maintain Fall Prevention Interventions for High-Risk Resident

South Holland, Illinois Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement and maintain fall prevention measures for a resident identified as high risk for falls. The resident is an adult with multiple complex medical conditions, including chronic respiratory failure with hypoxia, tracheostomy with ventilator dependence, gastrostomy, a prior displaced intertrochanteric fracture of the left femur with routine healing, essential hypertension, seizure disorder, anxiety disorder, adjustment disorder with depressed mood, major depressive disorder, generalized edema, left hip pain, diaphragmatic hernia, and delirium due to a known physiological condition. A facility incident report shows that on 10/21/25 the resident was found lying on the floor on the left side, reported left lower extremity pain, and an x‑ray revealed an acute intertrochanteric fracture of the proximal left femur, after which the physician ordered transfer to the hospital. The resident’s fall risk scale dated 10/26/25 identifies the resident as high risk for falling, and the care plan dated 2/27/25 documents high fall risk related to gait/balance problems, poor communication/comprehension, decreased safety awareness, and adverse behaviors, with interventions including keeping furniture locked, educating the resident to use the call light, and bilateral floor mats added on 10/21/25.

On 1/20/26 at 1:00 PM, the resident was observed in bed with only one floor mat on the right side of the bed and no floor mat on the left side, despite the care plan intervention for bilateral floor mats. At that time, the Assistant DON stated she had moved the left-side floor mat to place the bedside table so the resident could eat lunch and that she would return after the resident finished eating, leaving the resident in the room unsupervised. Later that day at 2:42 PM, the DON acknowledged that the resident should have been out of bed in a wheelchair in a highly visible area for monitoring because of the high fall risk. The facility’s Fall Prevention Program policy, revised 11/21/17, requires assessment of fall risk, implementation of appropriate safety interventions, and incorporation of fall interventions into the care plan, including informing nursing personnel of residents at risk and maintaining safety interventions for those residents. The record review also shows that after the addition of bilateral floor mats on 10/21/25, entries dated 11/29/25 and 12/1/25 list “no intervention,” indicating no documented changes or additions to fall interventions following the resident’s fall.