F0689

G

Failure to Prevent Door-Related Fall and Unsafe Post-Fall Transfer

Aledo, Illinois Survey Completed on 02-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident with dementia, identified as a wanderer with a history of falls and a prior right hip fracture, was adequately supervised and kept away from the dementia unit doors, despite known risks. The resident’s care plan documented risk factors requiring monitoring and interventions such as disguising exits, covering doorknobs and handles, and distracting the resident from wandering. Staff and the resident’s son reported that the resident had previously been struck by the same unit doors without injury, and staff were aware that the resident tended to stand behind the doors. On the date of the incident, a dietary cook entered the code and pushed open the double doors to bring in a lunch cart, did not see the resident standing in the crack between the door and the wall, and the door hit the resident, causing her to fall. An emergency room radiology report later showed a right femur fracture and right hip dislocation.

The facility also failed to ensure a safe transfer of the resident after the fall. After the resident was found sitting on the floor by the doors, the dietary cook and a CNA lifted the resident from the floor without using a gait belt or any assistive device and placed her into a wheelchair, even though the resident could only bear weight on one leg. Both staff later acknowledged that they did not use a gait belt, that moving the resident before a nurse assessed her could worsen any injury, and that it was not safe to transfer her in this manner. The facility’s transfer policy stated that mechanical lifting devices should be used for any resident needing a two-person assist or who could not be transferred comfortably and safely by normal transfer technique, and that manual lifting was not permitted except in emergency or unavoidable circumstances.