F0689

G

Failure to Provide Required 1:1 Supervision for High Fall-Risk Resident

Rockford, Illinois Survey Completed on 01-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure fall prevention interventions were in place for a resident with a known history of falls and behavioral symptoms. The resident had Alzheimer’s disease and dementia, was cognitively impaired, alert only to self, had poor safety awareness and impaired decision-making, and required frequent redirection. The care plan dated 12/12/25 identified that the resident did not stay in a chair, removed alarms, and needed 1:1 staff supervision throughout the day when experiencing increased anxiety, restlessness, and yelling. A fall risk assessment and Minimum Data Set documented that the resident was at high risk for falls due to abnormal gait or balance, medications that could impair balance, conditions affecting ambulation, and cognitive impairment with poor decision-making.

In the hours leading up to the fall, progress notes documented significant behavioral issues and sleep disturbance. On 12/22/25 at 11:01 PM, the resident was noted as disruptive, crying, yelling/screaming, having sleeping problems, feeling angry/anxious, and feeling restless/anxious. A subsequent progress note on 12/23/25 at 4:44 AM recorded that the resident was awake all shift. Staff interviews confirmed that on the night of the fall, the resident had been “up and busy all night,” not sleeping, and was kept at the nurse’s station due to these behaviors and attempts to get out of bed. The DON and the nurse practitioner both stated that, per the care plan, the resident should have 1:1 care when exhibiting such anxious, restless, and standing behaviors.

Despite these identified risks and care plan directives, the resident was left unsupervised at the nurse’s station. The LPN reported that she had the resident sitting with her at the nurse’s station because of the resident’s behaviors, then left the nurse’s station to go on break, leaving the resident there alone and only informing a CNA who was seated around the corner at the beginning of another hall and could not see the resident. Within minutes, staff heard the resident’s alarm and screaming and found the resident on the floor on her right side by the nurse’s station, with no nurse present. The progress note and emergency department documentation show that the resident sustained a right intertrochanteric hip fracture and a right patellar fracture, requiring hospital admission and surgical repair. The facility’s fall policy states that on admission and readmission, a fall risk assessment will be completed and interventions implemented for residents at risk for falls, but the required 1:1 supervision intervention was not in place at the time of the fall.