F0689

J

Failure to Maintain Hazard-Free Environment and Adequate Supervision Resulting in Severe Injuries

South Holland, Illinois Survey Completed on 02-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a hazard‑free environment and provide adequate supervision, resulting in serious injuries to two residents. One resident with Alzheimer’s disease, dementia, insomnia, palliative care, restlessness, agitation, and a history of falls had a BIMS score of 7, indicating severely impaired cognition. Her care plans documented poor balance, decreased strength, impaired ambulation, limited mobility, and the need for substantial/maximal assistance with bed mobility and transfers, including one‑person assistance and mechanical lift designation. She was also on hospice for end‑stage Alzheimer’s disease, required total care with ADLs, was nonverbal or minimally verbal, impulsive, frequently attempted to get up on her own, and was considered at high risk for falls.

On the night of the incident, the resident’s bed was a low bed positioned near a floor radiator heater. The CNA assigned to her shift from 11:00 p.m. to 7:00 a.m. stated she did not complete required two‑hour rounds, admitting she initially rounded at the start of the shift and then not again until approximately 4:45–5:00 a.m. She reported that the privacy curtain around the resident’s bed was pulled fully across and that she did not see the resident at all during the shift prior to discovering the fall. The CNA and another CNA had spent about 30 minutes assisting another resident back to bed, after which the assigned CNA focused on documenting point‑of‑care tasks instead of rounding. The CNA acknowledged she was negligent in not doing her rounds and stated that the resident was confused, tried to get up all the time, and was not steady on her feet.

Around 5:15 a.m., the CNA called the LPN/charge nurse into the room, where the resident was found lying on her right side between the bed and the wall, directly on the exposed floor radiator heater with the heater cover off. The LPN and CNA assisted the resident back to bed and noted blistered areas on the right shoulder and right hip. Facility internal documentation and hospital records described multiple intact and burst blisters, areas of pink flesh, charred skin, subcutaneous tissue exposure, and deep burns down to and through deltoid muscle, requiring debridement and split‑thickness skin grafts to the right upper and lower extremities. The LPN reported that she had last seen the resident around 3:00–3:15 a.m. sleeping, while the CNA stated she had not seen the resident at all before the incident. Staff interviews indicated that the radiator heater cover in this room had been loose or coming off for months, with multiple staff (a CNA and an LPN) stating the cover was in disrepair and would come off prior to the incident, and the CNA stating the cover had been off for over nine months.

The facility’s Administrator acknowledged that at the time of the incident the radiator cover in the resident’s room was not attached and believed it came off when the resident fell out of bed. However, the CNA and another CNA reported that the radiator cover had been loose or off for an extended period before the incident, and an LPN stated it had been that way for at least a couple of months, despite housekeeping cleaning the room daily. The Maintenance Director confirmed there had been no documented protocol or regular documentation of radiator heater checks prior to the incident and that only hot water and common area temperatures were being monitored. He also confirmed that two screws on each end were needed to secure the heater covers and that the resident was thin enough to fit between the radiator and the floor. These combined failures—lack of timely supervision/rounding for a cognitively impaired, high‑fall‑risk resident and failure to identify and correct a known physical hazard (an unsecured radiator heater cover adjacent to the resident’s bed)—led to the resident’s prolonged contact with the uncovered heater and the resulting severe burn injuries.

The deficiency also involved another resident who suffered a laceration to the left eye requiring sutures and traumatic subdural hematomas that required ICU admission and ultimately resulted in hospice admission due to the subdural hematoma. This second resident was one of four reviewed for hazards/supervision and was noted in the deficiency statement as an additional example of the facility’s failure to provide a hazard‑free environment and adequate supervision to prevent accidents. The report attributes both residents’ injuries to the facility’s failure to ensure the environment was free from accident hazards and to provide sufficient supervision to prevent accidents.

Removal Plan

• Visited all resident rooms on all units and rearranged beds as necessary to ensure no beds are pushed against walls or close to heating units.
• Placed bedside cabinets/nightstands between the bed and the wall that houses the floor radiator to provide separation from bed to wall; continued monitoring with education provided to residents who resisted.
• Removed R1’s bed from the wall and heating unit.
• In-serviced on-duty nursing staff and housekeepers that no resident beds are to be pushed to walls or close to heating units and that bedside cabinets/nightstands are to be placed between bed and wall radiators.
• Provided verbal education to staff on safety protocol covering: not positioning beds against walls; not positioning beds close to heating units; ensuring proper protection/covering of wall heating units; importance of visual rounds/increased visual monitoring; consequences for noncompliance; use of bedside cabinets/nightstands as separation; and fall prevention program.
• Discussed the R1 incident with the IDT as an impromptu QAPI with instructions to increase visual rounding on all units and scheduled follow-up discussion at the next QAPI.
• In-serviced staff on hourly rounding and implemented an hourly rounding form.
• In-serviced nurses and CNAs verbally on: not positioning beds against walls; not positioning beds close to heating units; placing bedside cabinets/nightstands between bed and wall radiators; ensuring proper protection/covering of wall heating units; importance of visual rounds/increased visual monitoring; consequences for noncompliance; and fall prevention program.
• Implemented a system for preventive maintenance rounds in all resident rooms: Maintenance Director and Assistant Director perform rounds daily when on duty; on weekends, each housekeeper performs rounds on assigned units; needed repairs reported immediately; if a potentially harmful repair cannot be completed immediately, resident will be placed in an alternate room until repair is completed.
• Checked heating units for secure protective coverings, with ongoing daily monitoring by Maintenance Director/assistant and weekend housekeepers.
• Initiated hourly rounding with recordings on all units.
• Assigned oversight/monitoring responsibilities for compliance during routine daily rounds; in their absence, Charge Nurse, Facility Manager on Duty, and assigned weekend housekeepers monitor compliance.
• Brought the event to the monthly QAPI meeting for discussion and re-evaluation of interventions, with additional interventions to be implemented if needed.