F0689

G

Failure to Implement Fall Precautions for High-Risk Resident Resulting in Hip Fracture

Kankakee, Illinois Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement fall precautions for a resident who was identified as high risk for falls upon admission. The resident was admitted with a primary diagnosis of left pubis fracture and additional conditions including unsteadiness on feet, gait and mobility abnormalities, cognitive communication deficit, dizziness, osteoarthritis, and a history of falls. An agency LPN completed an admission Fall Risk Evaluation that documented recent falls, incontinence, predisposing conditions, recent hospitalization, and use of medications increasing fall risk, resulting in a high fall risk score. Despite this, no fall precautions or interventions were triggered or implemented from this evaluation, and no fall risk care plan or interventions were documented in the at-risk plan prior to the incident.

On the date of the fall, the LPN caring for the resident reported hearing the resident yelling and found her on the floor at the foot of the bed, lying on her right hip and supporting herself with her right hand. The resident was confused, attempted to stand and walk to her closet, and stated she was trying to get her clothes to go home. The LPN stated she was not aware of any fall precautions in place for the resident at that time. Subsequent review by the acting ADON confirmed that the nurse who completed the fall risk assessment did not implement any fall precautions when prompted by the electronic health record, and that no fall interventions were in place before the fall. The NP stated that facility protocol requires fall precautions for any resident assessed as high fall risk, which should have been done for this resident. Following the fall, an emergency room X-ray documented an acute right intertrochanteric hip fracture.