F0689

G

Failure to Adequately Supervise High Fall-Risk Residents Resulting in Multiple Injuries

Orland Park, Illinois Survey Completed on 02-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision and monitoring, including maintaining visual oversight, for residents assessed as at risk for falls, in accordance with their care plans and assessed needs. One resident with dementia, a history of falls, orthostatic hypotension, syncope, and severely impaired decision-making was housed on a locked dementia unit and identified as at risk for falls. This resident had an unsteady gait, wandered, and exhibited behaviors of trying to get up and walk unassisted. Despite being at the nurse’s station in a wheelchair prior to the first fall, the resident was later found on the floor in a staff bathroom located within a locked nurse’s closet that required a code to enter. Staff reported that the closet door was usually kept closed and coded, and a nurse stated that someone must have left the door open. The fall was unwitnessed, and the resident sustained a scalp laceration requiring staples.

Subsequently, the same resident experienced another fall in the dining room. The resident’s care plan identified her as at risk for falls due to history of falls, weakness, impaired balance and mobility, impaired cognition, wandering, and hypotension, with interventions including monitoring for attempts to get out of a chair or ambulate without an assistive device and cueing the resident accordingly. Progress notes and behavior charting documented that the resident was restless, crying, yelling, attempting to ambulate unsafely without staff assistance, and that interventions such as walking her around the unit and offering activities did not fully resolve these behaviors. On the day of the dining room fall, staff brought the resident to the dining area in a wheelchair and locked the wheelchair at the table. Multiple staff were present in the dining room but reported they did not actually see the fall. Statements indicated that the resident stood up from the wheelchair, walked around the table, and fell before staff could reach her, resulting in a left femur fracture.

Another resident with dementia, impaired short- and long-term memory, unsteady gait, use of a rollator, history of falls, and multiple risk factors including hypertension medications, antidepressants, seizure history, COPD, and occasional incontinence was also assessed as at risk for falls. This resident required supervision or touching assistance for sit-to-stand transfers and, according to a nurse, required monitoring every fifteen minutes and should not be left alone in her room unless asleep. The nurse reported that the resident was kept near the nursing station for monitoring and that the resident was forgetful and needed encouragement to use her rollator. On the day of the incident, the nurse last saw the resident in her room sitting on the bed or rollator seat, then later heard the resident yelling and found her on the floor by the window, with a hematoma on the top of her head, lip bleeding, and complaints of arm pain. The fall was unwitnessed, the resident’s walker was not near her, and she stated she had been going to answer a telephone that was not present in the room. Hospital records documented an unwitnessed fall with head injury, lip laceration, scalp abrasion, a right supracondylar humerus fracture, and intracerebral hemorrhage. These events occurred despite facility policies stating a commitment to proactively identify residents at risk for falls, plan preventive strategies, and assess and monitor the resident’s environment to manage potential hazards.

The facility’s fall management policies stated that hazards and risks would be assessed, plans of care developed and implemented, and the environment monitored to minimize fall incidents and injuries. However, in these cases, residents with known dementia, impaired cognition, unsteady gait, and documented fall risk were able to access unsafe areas or ambulate without adequate supervision. The first resident accessed a staff-only bathroom through a coded nurse’s closet and fell without staff present, and later ambulated around a dining room table and fell while staff were in the room but without continuous visual oversight. The second resident, who staff acknowledged should not be left alone in her room unless asleep and required frequent monitoring, was left unsupervised in her room, ambulated without her rollator, and sustained an unwitnessed fall with significant injuries. These circumstances demonstrate that the facility did not consistently maintain the level of supervision and environmental control described in residents’ assessments, care plans, and facility policies for fall prevention.