F0689

G

Failure to Implement Fall-Prevention, ADL Assistance, and Post-Fall Pain Assessment for High-Risk Resident

Chicago, Illinois Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision and care in accordance with the resident’s assessed needs and care plan. Resident R2 was identified as bedbound, nonverbal, severely cognitively impaired (BIMS score 00), with multiple contractures of all extremities, functional quadriplegia, and a history of a displaced subtrochanteric fracture of the left femur. R2’s MDS documented total dependence for bed mobility and all ADLs, requiring the assistance of two or more helpers, and the restorative nurse confirmed that R2 was assessed as a two‑person ADL assist and a high fall risk prior to the incident. R2’s care plan and facility policies required that the bed be maintained in the lowest position, that approved repositioning techniques be used, and that the call light be kept within reach for safety.

On the evening of 1/4/2026, CNA V11, who was assigned as R2’s primary CNA, provided in‑bed ADL/linen care to R2 alone, without a second staff member, despite R2’s documented need for two‑person assistance. V11 reported that R2 was bedbound, nonverbal, contracted in both arms and legs, and had a floor mat next to the bed. While changing linens, V11 moved the bed away from the wall, positioned themself between the bed and the wall, and turned R2 onto the right side, away from V11, to tuck a clean linen roll under R2. When V11 realized a new incontinence brief was not within reach, V11 leaned over R2 and pressed an arm into the low air loss mattress to reach for the brief at the foot of the bed. This caused R2 to slide toward the opposite edge of the bed. As R2 began to fall, V11 attempted to stop the fall by grabbing R2’s leg, but R2 continued to slide off the bed, landing partly on the floor mat and partly on the floor, with the head slightly off the mat. V11 observed pain in R2’s facial expression when grabbing the leg and reported seeing that R2 was in pain.

LPN V8, who responded immediately while covering the primary nurse’s assignment, found R2 on the left side on the floor mat with a bleeding laceration on the left forehead. V8 performed a post‑fall assessment, palpating along R2’s contracted extremities and noted that when the left leg was palpated from the knee up to the hip, R2 grimaced and made moaning noises, indicating pain in the left leg. V8 cleansed and dressed the forehead laceration and assisted with lifting R2 back to bed, then medicated R2 with PRN acetaminophen. However, when V8 spoke with the APN (V31) during the post‑fall notification process, V8 did not report the new left leg pain findings from the assessment. The APN’s progress note documented a witnessed fall with a small head laceration and “no active pain, bleeding or complaints,” and no new orders were issued on the date of the fall. Subsequent documentation and interviews showed that R2 continued to exhibit pain and moaning with palpation of the left lower extremity, and an X‑ray obtained two days later revealed a proximal left femur fracture. The facility’s DON and NP both stated that nurses are expected to recognize and report nonverbal signs of pain, especially in nonverbal, contracted residents after a fall, and that new pain post‑fall should be communicated to the practitioner for possible imaging, but this did not occur immediately after R2’s fall.

Additional observations by the surveyor and staff interviews highlighted further failures to consistently implement fall‑prevention interventions already in R2’s care plan and facility policies. R2 was listed on the unit’s high fall risk roster, and the restorative nurse stated that for bedbound residents, staff are to keep the bed in the lowest position, position the resident in the center of the bed during care, and ensure the call light is within reach. However, on a later observation date, R2’s bed was found at a higher position than previously observed, and the adaptive call light pad was hanging over the headboard toward the wall, away from R2, until an LPN lowered the bed and repositioned the call light near R2’s head. The primary nurse on the evening of the fall (V7) acknowledged that R2 was a two‑person assist for ADLs but did not inform the new CNA (V11) of this requirement at the beginning of the shift, only reiterating it after the fall. Collectively, these actions and omissions show that the facility did not follow its own fall prevention, ADL assistance, call light, and pain management policies for a high‑risk, fully dependent resident, resulting in a fall from bed with a head laceration and unreported post‑fall leg pain that was later associated with a left femur fracture.

Family interviews further described the condition of R2 immediately after the fall and in the days following. R2’s healthcare power of attorney and another family member reported arriving shortly after being notified of the fall and observing blood dripping from the left side of R2’s head and blood on the floor. They questioned the nurse about sending R2 to the hospital for examination and were told that R2 was stable and would be monitored in the facility per practitioner direction. They also reported asking whether a full body examination for possible broken bones would be done and were told it would be performed. On 1/6/2026, the family was informed by facility staff that imaging suggested possible bilateral hip fractures, and later at the hospital they were told that R2 had a comminuted displaced left femur fracture. The family stated that R2 was in significant pain, making loud noises, and that they received conflicting information from the facility about the nature of R2’s injuries. These accounts align with the clinical findings that R2 exhibited nonverbal signs of pain in the left leg after the fall, which were not promptly communicated to the practitioner at the time of the initial post‑fall assessment.