F0689

D

Failure to Supervise High Fall-Risk Resident During Toileting

Rockford, Illinois Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

Failure to ensure adequate supervision during toileting occurred when a cognitively impaired, high fall-risk resident with Alzheimer's disease and dementia was left alone in the bathroom and subsequently sustained a fall with injury. The resident’s records, including a Morse Fall Scale dated 2/16/26, identified her as high risk for falls due to a history of falling, impaired gait, and a tendency to overestimate or forget her limits. Her MDS indicated she was not cognitively intact and required substantial/maximal assistance with toileting, and her care plan documented impaired cognitive function, confusion, impaired balance, and high fall risk related to gait/balance problems. Staff interviews confirmed that she was “pleasantly confused,” frequently tried to get up on her own, and was considered a high fall risk who should not be left alone in the bathroom.

On the evening of the incident, a CNA assisted the resident to the toilet while the resident’s daughter was present in the room. The resident requested privacy, and the daughter told the CNA it was acceptable to leave because she would remain in the room. The CNA left the room and began passing drinks to other residents. The daughter then informed the CNA in the hallway that she was leaving and that the resident was still on the toilet, explaining she did not want her mother to see her leave. The CNA continued passing drinks to a few more residents before returning to check on the resident, at which time the resident was found on the bathroom floor sitting on her buttocks. The nurse’s assessment and the facility’s incident report documented that the fall was unwitnessed, occurred in the bathroom while the resident was attempting to self-transfer, and resulted in a left 4th finger fracture identified on ER imaging.