F0689

G

Failure to Adequately Supervise High-Risk Residents Resulting in Unwitnessed Femur Fracture and Unattended High-Fall-Risk Residents

Chicago, Illinois Survey Completed on 01-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision and monitoring to prevent accidents for three residents, including one who sustained a left femoral fracture. One resident had multiple diagnoses including essential hypertension, type 2 diabetes with neuropathy, cerebrovascular disease, muscle weakness, abnormalities of gait and mobility, muscle wasting, weakness, unsteadiness on feet, and unspecified convulsions. This resident’s MDS showed significant cognitive impairment with a BIMS score of 6/15 and documented need for supervision with ADLs and mobility. The resident’s care plan stated that a safe environment was to be maintained and that staff should anticipate and meet needs and provide a safe environment. A community survival skills assessment documented that the resident did not appear capable of unsupervised outside pass privileges.

On 12/11/2025, staff identified a change in this resident’s condition related to mobility and gait. The restorative nurse received a report that the resident was experiencing increased unsteadiness in gait. Upon assessment, the resident reported that his left knee sometimes gave out. A wheelchair and urinal were provided, and the resident was educated on safe wheelchair use and encouraged to request staff assistance. A change in condition note by an LPN the same day documented that the resident needed two-person assistance to bed due to left leg weakness, later proceeded to walk without staff after resting, and that his gait was not at baseline, though it showed some improvement. Another note documented that the resident was later seen leaning on the bathroom door, unable to use his left leg during transfer, and that he walked into the dining area for dinner with a shuffled gait that was not baseline. The care plan and progress notes from 12/11/2025 to 12/16/2025 did not document any ongoing non-compliance with wheelchair use or additional interventions related to his increased unsteadiness.

On 12/16/2025, the LPN documented that the resident complained of left leg pain starting at the groin and radiating down the thigh, with pain on movement but not on light touch, and the resident was sent to the hospital for evaluation. Hospital records showed a left basicervical femoral neck fracture, and the resident was described as a very poor historian, alert and oriented x1, unable to explain why he was brought to the ED, and unable to recall the mechanism or timing of injury. The hospital record noted that no information was provided from the nursing home and that family could not be reached. The social services director stated that the resident did not go into the community independently and that any community pass would be documented; review of progress notes and the Resident Community Access Tracking Tool for December 2025 showed no documentation that the resident went out on community pass. Despite the resident’s impaired cognition, unsteady gait, and documented change in condition, there was no clear documentation of how the fracture occurred while the resident was in the facility.

The deficiency also includes inadequate supervision of two additional residents who were both assessed as high fall risk. On observation, two residents were seen sitting in geri-chairs in the second-floor dining room unsupervised and unattended. Their fall risk assessments documented high fall risk scores (13 and 12), and their care plans included impaired cognition, history of falls, muscle weakness, dementia, impaired decision-making, and the need for cueing, reorientation, supervision, fall precautions, and maintenance of a safe environment with fall interventions in place. An LPN stated that CNAs take turns monitoring residents in the dining room at 30-minute intervals to ensure residents do not fall, injure themselves, choke, or get into physical altercations, and that a specific CNA was assigned to monitor the dining room during the time of observation. Despite this assignment and the facility’s policies on standard supervision and incidents/accidents/falls, the two high-risk residents were left in the dining room without staff present, demonstrating a failure to provide the supervision and monitoring required by their assessed needs and care plans.