F0689

G

Failure to Maintain Fall Mat Intervention Resulting in Resident Head Injury

Decatur, Illinois Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement and maintain fall prevention interventions as outlined in its Fall Prevention Program for a resident assessed as being at risk for falls. The facility’s policy dated 2/2/26 states that each resident’s fall risk will be assessed and interventions implemented to decrease the risk of falls and injuries. The resident had medical diagnoses including abnormalities of gait and mobility, lack of coordination, muscle weakness, and altered mental status. An MDS documented that the resident was moderately cognitively impaired and required moderate staff assistance for transfers. The resident’s care plan dated 1/7/26 identified risk for falls related to muscle weakness and included an intervention for floor mats to be placed on the side of the bed, implemented on 1/6/26.

On 1/25/26, nursing notes documented that the resident was found on the floor on the right side of the bed in a fetal position, reporting that they had fallen from the bed and that their head and neck hurt, with blood noted on the right side of the head. A CT scan from that date showed mild subcutaneous soft tissue swelling and a hematoma in the right posterior parietal region, along with subcutaneous emphysema consistent with a laceration, and emergency room records documented a head laceration requiring five staples. The RN assigned to the resident during the overnight shift confirmed that at the time of the fall, the fall floor mats were not in place at the bedside, despite being a previously implemented intervention. The President of Clinical Services confirmed that fall mats had been put in place as a fall prevention intervention earlier in the month and that they should have been on the floor when the resident was in bed and at the time of the fall.