F0684

D

Resident Moved After Fall Without Prior Nursing Assessment

Aledo, Illinois Survey Completed on 02-09-2026

Penalty

No penalty information released

Summary

The facility failed to ensure a resident was assessed for injury after a fall and prior to being transferred. The resident had been admitted with a primary diagnosis of unspecified dementia without behavioral, psychotic, mood disturbance, or anxiety features. An incident report documented that the resident was ambulating in the hallway behind double doors when the doors were opened, causing a change of plane and resulting in the resident falling, with noted discomfort to the right side. The dietary cook reported that she pushed the lunch cart through the double doors after entering a code and did not see the resident positioned by the crack between the door and the wall. When the door opened, the resident fell.

Following the fall, the dietary cook went to get a CNA, and together they picked the resident up from the floor, stood her up, and placed her in a wheelchair, without using a gait belt and before a nurse could assess the resident. The CNA confirmed that she stood the resident up and transferred her to a wheelchair without a gait belt and acknowledged that moving the resident before a nurse assessment could worsen any injury. The LPN stated she returned from break to find the resident already in a wheelchair and that the aides had gotten the resident up before she could perform an assessment, noting they should not have moved the resident in case of a possible broken hip. The DON stated that after a fall, the nurse should perform an assessment first, including range of motion, pain level, and vital signs, and that the resident should not be moved prior to this assessment. The facility’s fall prevention policy indicated that transfer conveyances should be used in accordance with the care plan, and the DON noted there was no specific checklist for post-fall assessments.