F0689

G

Failure to Implement Targeted Fall Interventions and Complete Post-Fall Neurological Assessments

Charleston, Illinois Survey Completed on 02-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement appropriate fall-prevention interventions, ensure needed mobility devices were within reach, and complete required post-fall assessments and notifications for a resident with severe cognitive impairment. The resident had multiple significant diagnoses, including senile degeneration of the brain, chronic respiratory failure with hypoxia, hypertensive heart disease with heart failure, chronic kidney disease stage IV, unsteadiness on feet, and lack of coordination. An MDS documented a Brief Interview of Mental Status score of 5/15, indicating severe cognitive impairment, and that the resident required supervision and contact assistance with toileting and used a wheelchair for mobility.

On one date, the resident experienced an unwitnessed fall while attempting to get up to go to the bathroom and fell over a recliner chair footrest, striking her face on the floor. The fall investigation documented that the resident’s POA requested hospital transfer, and the resident returned with a small head laceration and no new orders. The facility’s fall log listed the intervention as ensuring the call light was within reach and functioning, an intervention that had already been in place and which the DON later confirmed was not appropriate for a resident with severe cognitive impairment. No new targeted interventions addressing toileting needs or the recliner footrest were documented after this fall. Later in the same month, the resident had another unwitnessed fall, was found on the floor, and could not state what happened. The only intervention documented was to educate the resident to use the call light and wait for assistance, which the DON again confirmed was not appropriate given the resident’s cognitive status.

On a subsequent date, the resident had another unwitnessed fall while moving from one bed to another and was found on the floor between the bed and bathroom. The fall report documented a small bump to the head near the right eye, that vital signs were taken, the resident was helped back to bed, and again instructed to use the call light for help. The CNA who found the resident stated the wheelchair was across the room, out of the resident’s reach, despite a care plan intervention that assistive devices be kept within reach. The CNA reported the resident was mumbling, groaning, appeared in pain, had a large bump above the right eyebrow that swelled immediately, and was without oxygen. The CNA stated the LPN did not assess the resident, directed staff to get her up, and left the room, with another CNA later obtaining vital signs. The neurological assessment flow sheet initiated after this fall showed the resident as stuporous and unable to follow directions at the initial time, but all other required neurological and vital sign fields were left blank at that time and at all subsequent required intervals, with no nurse signature. The DON confirmed that neurological assessments were not completed, that there was no thorough investigation to determine root cause, and that appropriate notifications to family, physician, and hospice were not made. The MAR showed that ordered PRN lorazepam and morphine were not administered on the date of the fall, while family and hospice staff later reported the resident was lethargic, moaning, swollen and bruised, and appeared to have suffered a serious head injury and untreated pain. The facility’s own fall reduction and neurological assessment policies required evaluation for injury, neurological assessment for possible head injury, and timely notification of physician, responsible party, and hospice, which were not carried out in this case.

Family members stated they were not notified of the fall when it occurred and only learned of it later, expressing that they would have come in immediately had they been informed. They also reported being told by a CNA that the nurse instructed CNAs to get the resident off the floor and back to bed without the nurse completing an assessment, and that the nurse said she would give morphine but was later observed at the desk on her phone and reading. Another LPN reported that when she came on duty the next day, there was no documentation that the prior LPN had completed neurological assessments or contacted the physician, hospice, or family, and that she herself then attempted to reach family and hospice, who came in right away. The hospice RN confirmed hospice was not notified until the following morning, despite hospice protocol requiring immediate notification of falls so hospice staff can assess the resident. The hospice RN described the resident as having been alert and conversational the day before the fall and as lethargic and unable to converse when seen the next morning, and stated that, based on her experience, the resident had likely sustained a concussion and brain bleed and needed earlier evaluation.

The DON, after reviewing the fall investigations, care plans, assessments, neurological assessments, vital-sign documentation, interventions, and fall reports, confirmed that standard practice to thoroughly assess a resident post-fall was not followed. The DON verified that the interventions of reminding the resident to use the call light were not appropriate for a resident with severe cognitive impairment, that toileting should have been addressed after the first fall when the resident was attempting to go to the bathroom independently, that neurological assessments were not completed after the last fall, and that appropriate notifications to family, physician, and hospice were not made. The facility’s written policies on fall reduction and neurological assessment, which require evaluation for injury, use of neurological assessment guidelines for possible head injuries, and timely notification of physician, responsible party, and on-call nurse, were not adhered to in the resident’s case.