F0684

D

Failure to Assess, Document, and Communicate Resident Fall

Wauconda, Illinois Survey Completed on 01-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely communicate and document a fall, complete a post-fall assessment, perform subsequent assessments, and implement fall-prevention interventions for one resident. The resident was admitted for short-term rehabilitation with a medical history including seizures, anemia, hypertension, anxiety, osteoarthritis of the left wrist, and chronic kidney disease. On admission, a fall risk assessment scored the resident as not at risk for falls, but a subsequent assessment two days later identified the resident as at risk, and the care plan was updated to reflect fall risk. An unwitnessed fall incident occurred when the resident rolled or fell from the right side of the bed onto a landing pad while restless and hard to redirect, and the resident was unable to describe the event due to cognitive deficits. Staff, including a CNA and an RN, later confirmed that the resident had fallen from the bed.

The unwitnessed fall report documented the incident time and basic description but lacked documentation of notifications to agencies or people, and there was no documented date of when the incident report itself was completed. Although staff reported that the nurse was called and assessed the resident, the record did not contain a completed post-fall assessment or any subsequent assessments following the fall. The facility’s Fall Prevention Program policy required fall risk assessments upon admission, quarterly, with significant changes, and after any fall incident, as well as implementation of safety interventions and communication with direct care staff, physician, and family/legal representative. The survey findings indicate that these required assessments, documentation, and interventions were not carried out or recorded as required for this resident following the fall event.