F0689

D

Failure to Implement Fall Prevention and Maintain Functional Emergency Exit Door

Homewood, Illinois Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement fall prevention interventions and provide adequate supervision for a high fall-risk resident, as well as failure to maintain a functional, alarmed emergency exit door on a dementia unit. One resident, an elderly individual with dementia, metabolic encephalopathy, adult failure to thrive, muscle wasting/atrophy, lack of coordination, repeated falls, and a high fall risk score of 21, was admitted with severe cognitive impairment (BIMS score of 7) and required substantial/maximal assistance for bed-to-chair transfers, with walking not attempted. The resident’s care plan identified high fall risk and included an intervention to move the resident to a room with optimal visual access from the nurse’s station and to have staff assist as needed.

On the date of the incident, progress notes documented that at 5:24 PM the resident was found on the floor on the right side of the bed in a prone position, with a raised area on the left forehead. The resident was assisted off the floor and returned to bed. At 5:54 PM, it was documented that the resident, who was alert to self only with confusion and unable to recall the event, again rolled out of bed and was found on the floor, still with a raised area on the left forehead and no bleeding or bruising noted. The incident report described the fall as unwitnessed, with predisposing factors including confusion, impaired memory, and antipsychotic use. EMS records noted a 3-inch hematoma on the left forehead and that the resident was taking Eliquis, and the hospital history and physical documented a moderate left frontal scalp hematoma and possible trace subdural hemorrhage on CT. The facility’s fall prevention policy required identification of high-risk residents, implementation of interventions, and updating the care plan with new interventions after each fall based on root cause analysis.

A separate deficiency was identified regarding the 300 unit emergency exit door serving a dementia care unit with 12 residents. Observation showed that the emergency door alarm light at the top of the door was not illuminated despite posted instructions that the door would alarm and unlock after holding the push bar for 15 seconds. When the Maintenance Director tested the door by holding the push bar, no alarm sounded and, after 20 seconds, the door remained locked. The door only opened approximately 12 inches at the bottom when the Maintenance Director applied full body weight, and on a final attempt an alarm sounded but the lock still did not disengage. The Maintenance Director stated that the unit is a dementia care unit, that the alarm is intended to prevent elopement, and that the lock should disengage to allow staff and residents to escape in an emergency. The facility’s preventative maintenance policy assigned responsibility for checking the operation of fire doors to the Maintenance Director.