F0689

G

Failure to Supervise Cognitively Impaired Residents and Complete Thorough Fall Management

Clinton, Illinois Survey Completed on 01-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and fall prevention for cognitively impaired residents, resulting in repeat traumatic falls and incomplete post-fall management. One resident with dementia, syncope, difficulty walking, muscle wasting, pain, and severe cognitive impairment was assessed as at risk for falls and required staff assistance for transfers. This resident experienced an unwitnessed fall in the memory care living room, where staff overheard a gasp and then found the resident on the floor with a head impact, head pain, a large hematoma, a knee skin tear, knee pain, and new back and neck pain, requiring emergency transfer and multiple CT scans. Prior to this fall, pain assessments had not been positive, but immediately afterward the resident reported high pain scores.

The same resident, still identified as severely cognitively impaired and at risk for falls, later had another unwitnessed fall in the memory care dining room. Staff reported the resident repeatedly attempted to get up from a wheelchair and was redirected to sit, but at the time of the fall no staff were present because they were taking other residents to their rooms after supper. The resident attempted to self-transfer from the wheelchair, which rolled backward because the brakes were not applied, resulting in a fall to the floor, a large forehead hematoma, complaints of dizziness and pain, and another emergency transfer with multiple CT scans and new pain medication orders. The DON reported the resident lacked safety awareness and frequently attempted to self-transfer, and also reported not being aware of the presence of auto-locking brakes on the resident’s wheelchair prior to this fall, despite these behaviors having occurred for a long time.

A second resident with severe cognitive impairment and total dependence for bed mobility experienced multiple falls with inadequate assessment, investigation, and monitoring. This resident had an unwitnessed fall after rolling out of bed onto a floor mat; the fall note documented confusion, a moderate pain score, and initiation of neurological checks, but the unwitnessed fall report did not identify environmental, physiological, or situational factors, and no fall risk assessment was completed before or after the fall. A subsequent fall was documented as witnessed, with the resident found partially out of bed and hanging from a side rail, but no CNA was identified and no witness statements were included, and required neurological assessments for 72 hours were only documented twice. There was no bedside side-rail assessment in the record, and after a third unwitnessed fall, safety checks were ordered but not documented as completed. The DON later confirmed deficiencies in fall investigations, assessments, neurological monitoring, care planning, and documentation, despite an existing fall prevention policy outlining required assessments, interventions, and documentation.