F0689

G

Failure to Monitor High Fall-Risk COVID Isolation Resident and Maintain Bed Safety

Morton Grove, Illinois Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and implementation of fall-prevention interventions for a bedbound, high fall-risk resident on strict COVID-19 isolation. The resident was an older male with multiple diagnoses including Type 2 diabetes with hyperglycemia, COVID-19, prior head injury with surgical aftercare, syncope and collapse, and paroxysmal atrial fibrillation. His MDS showed moderate cognitive impairment (BIMS 11), he used a wheelchair, and did not attempt to walk due to medical or safety concerns. A fall risk evaluation scored him as high risk (score 9). His care plan and fall coordinator documentation required the bed to be kept in the lowest position, use of two partial side rails, call light and personal items within reach, no clutter on the floor, and hourly checks for residents on isolation. Facility policy on routine resident checks required initial rounds at the start of the shift and at least every two hours thereafter, and the infection control/designee and DON stated that COVID isolation residents were to be monitored every hour, with nurses and CNAs alternating.

On the morning of the incident, the night nurse reported seeing the resident at 6:30 a.m. in bed, in the lowest position, sleeping comfortably, with no signs of distress. The night nurse stated that hourly monitoring was done but not documented, and that report was given to the day nurse. The day RN assigned to the resident began her shift at 7:00 a.m., received report that the resident had slept comfortably, and then passed morning medications until about 9:00 a.m. She acknowledged that she had not physically seen the resident at any time after starting her shift and assumed the CNA had seen him when passing breakfast trays. The agency CNA assigned to the resident stated that when she arrived for her 7:00 a.m.–3:00 p.m. shift, the night CNA was not present, she received no room-to-room report, and the nurse on duty said she was not familiar with the group. The CNA reported that she did not go room to room with the nurse and that the only information she received about the resident was that he needed to be checked and changed and that he had COVID.

The agency CNA stated that between approximately 8:00 and 8:15 a.m., she went to deliver the resident’s breakfast tray, found the bed empty, and assumed he was out for an appointment. She did not check the bathroom, did not look around the room or on the other side of the bed, and noted that the bed was not in a low position and that no side rails were up. She left the tray and continued passing other trays. About an hour later, she returned and found the tray untouched, asked the nurse about the resident’s whereabouts, and was told he might be at dialysis; she accepted this explanation, although the resident was not a dialysis patient, and left the tray to warm later. The day RN confirmed that she mistakenly told the CNA the resident might be at dialysis, confusing him with another resident, and did not verify his presence in the room despite his being on strict isolation and requiring monitoring every one to two hours.

Between 9:00 and 10:00 a.m., the social services director entered the resident’s isolation room after knocking and receiving no response, did not see him in bed, and then observed his feet and legs protruding from under the bed between the bed and the window. Most of his body was under the bed, and he was unresponsive. The social services director called for nursing staff. The rehab LPN and the day RN responded and found the resident lying between the heater and the bed, more under the bed, unresponsive, with no visible chest rise, no eye opening, and no communication. The bed was not in the lowest position. A code was called, CPR was initiated, oxygen was applied, and paramedics were summoned. Progress notes documented that at 9:12 a.m. the resident was found on the floor, unresponsive and not breathing, with blood pressure 106/66, pulse 171, respirations 0, and oxygen saturation 54% on room air. CPR and AED use were documented, and the resident was pronounced dead at 9:58 a.m. The death certificate listed cardiac arrhythmia, atrial fibrillation, and cerebrovascular disease as causes of death.

Interviews with multiple staff confirmed that the resident was bedbound, unable to walk, on strict COVID isolation in a private room with the door to be closed, and identified as high fall risk by the fall coordinator, who specified that the bed should always be in the low position with both quarter-length side rails up. The DON, medical director, infection preventionist, and other nurses described expectations that staff perform initial physical checks at the start of each shift, conduct at least every-two-hour rounds for all residents, and hourly checks for isolation residents, with documentation in progress notes for COVID residents. However, review of the resident’s progress notes showed no documentation of hourly monitoring from the time he was placed on isolation. Staff interviews revealed that the day RN did not physically verify the resident’s presence after receiving report, the agency CNA did not thoroughly search the room or verify his location when he was not in bed, and the nurse gave incorrect information that he might be at dialysis. The bed was observed not to be in the lowest position and side rails were not in use when the CNA first entered the room and when the resident was later found under the bed, indicating that required fall-prevention interventions were not consistently implemented. As a result, the resident was not visually observed or assessed for over two hours while on strict isolation and high fall risk status, culminating in his being found unresponsive on the floor under the bed and subsequently pronounced deceased in the facility.