F0689

D

Failure to Maintain Functional Alarms and Provide Adequate Supervision for High Fall-Risk Residents

Cicero, Illinois Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that adequate supervision and fall-prevention interventions were provided for residents at risk for falls. For one resident with autistic disorder, developmental motor disorder, and lack of coordination, the care plan identified a history of actual falls and included a self-releasing seat alarm belt as an intervention. The resident’s functional assessment showed a need for partial to moderate assistance with sit-to-stand and transfer activities, and the BIMS score indicated intact cognition. During observation, the resident was seated in a wheelchair with an alarm box behind the seat. When an LPN asked the resident to stand, the chair alarm did not sound. The LPN acknowledged the alarm was not working and appeared to be in the seatbelt, and there was no indication that defective equipment had been reported as required by the CNA job description and the facility’s fall prevention program, which identifies missing or broken equipment as a fall risk factor.

The facility also failed to implement appropriate fall-prevention interventions and supervision for another resident with dementia, schizoaffective disorder, a high fall risk score, and a nondisplaced intertrochanteric fracture of the right femur. Progress notes documented that this resident repeatedly attempted to throw himself out of a chair in the dining area while staff were monitoring the area. Later the same day, another note recorded that the resident leaped from the chair to the floor, after which he was assisted back to the chair and staff continued monitoring the dining area without initiating enhanced or one-to-one supervision. Subsequent notes described the resident being kept near the nurses’ station and requiring constant redirection due to restlessness and attempts to propel himself to his room, as well as repeated attempts to get out of his wheelchair in the dining room despite redirection. The resident’s care plans documented a history of actual falls, high fall risk related to cognitive impairment and mental illness with behavioral symptoms, and a need for extensive assistance with ADLs and one-person support for transfers.

Staff interviews confirmed that, at the time of the dining room fall, the resident was known to be impulsive, confused, and frequently attempting to stand or put himself on the floor. The CNA and LPN present in the dining room stated they were aware the resident was repeatedly trying to get out of the wheelchair but were positioned near the dining room doors rather than directly next to him. Both reported that by the time they reached the resident, he had already fallen, and the CNA acknowledged that if staff had been positioned directly next to the resident, the fall could have been prevented. The DON stated that when monitoring is increased, staff are expected to directly observe the resident, but also confirmed that a single staff member was responsible for monitoring several residents in the dining room and that the resident was not provided direct or constant one-to-one supervision despite his repeated attempts to exit the wheelchair. Facility policies on fall prevention and incidents/accidents/falls emphasized identifying fall risk factors, implementing individualized interventions, visually checking residents for safety, and reporting significant incidents and injuries, but the documented practices and staff accounts showed that these measures were not effectively implemented for the residents involved.

Additional documentation related to the second resident showed ongoing pain complaints and subsequent hospital evaluation revealing an age-indeterminate mildly displaced periprosthetic fracture of the right greater trochanter and displaced rib fractures, along with soft tissue swelling of the left humerus. Facility leadership and the attending physician acknowledged uncertainty about when the fractures occurred and whether they predated admission or were related to the documented fall, and the DON and Chief Nursing Officer indicated that no reportable incident was filed because the fracture was considered not acute and records from prior facilities were incomplete. The facility’s fall prevention and residents’ rights documents stated a commitment to safety, individualized fall risk assessment, appropriate interventions, and care that promotes quality of life, but the failures to ensure a functioning alarm for one resident and to provide adequate, individualized supervision and fall-prevention interventions for the other resident led to the cited deficiency.