F0689

G

Failure to Implement Fall-Prevention Measures and Prevent Elopement for High-Risk Residents

Moline, Illinois Survey Completed on 03-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement and follow individualized fall-prevention measures for one resident and to prevent an elopement for another resident identified as at risk. One resident (R4) had diagnoses including myasthenia gravis, dementia without behaviors, disorientation, a history of falls, and was assessed as having severe cognitive impairment. R4’s care plan, revised in February, specified fall interventions including a pool noodle to the left side of the bed, removal of the floor mat from in front of the bed, and ensuring the walker was within reach at bedtime. On a February morning, R4 experienced an unwitnessed fall while attempting to self-toilet, reporting that she tripped over a fall mat located next to the bed, resulting in a large forehead laceration and a bruised, painful left knee. Hospital records documented a 3 cm forehead laceration repaired with nine sutures.

Subsequent staff interviews and observations showed inconsistency between the care plan and the fall-prevention measures actually in place for R4. A CNA (V12) reported that R4’s fall-prevention measures included having mats on the floor on both sides of the bed, frequent checks at least every 15 minutes, and toileting offers, and stated that R4 sometimes picked up the mats and staff had to put them back down. During room observation, V12 confirmed there was no pool noodle on the left side of the bed, confirmed a fall mat on the right side between the bed and wall, and then placed an additional fall mat on the left side of the bed with the walker on top of it. In contrast, the Assistant DON (V3) stated that R4’s fall-prevention measures were a low bed, non-slip socks while in bed, removal of the fall mat in front of the bed, and keeping the walker within reach at bedtime, and further stated that a fall mat on the left side of the bed would pose more of a fall risk and should never have been used there.

The deficiency also includes the facility’s failure to prevent an elopement for a resident (R1) identified as an exit-seeking/elopement risk. R1 had multiple diagnoses including seizures, muscle weakness, gait and mobility abnormalities, dementia without behavioral disturbance, alcohol abuse, schizophrenia, acute kidney failure, visual disturbances, depression, and altered mental status, and was assessed as having moderate cognitive impairment with hallucinations and delusions, ambulating with supervision or touching assistance. R1 had an order for a Wanderguard on the left ankle and a care plan problem for exit seeking/elopement risk related to cognitive impairment, with the goal that he would not leave the center unattended. One evening, nursing documentation and staff interviews described R1 walking quickly through the unit, forcefully banging on an exit door near the nurse’s station, triggering alarms, then moving toward the front door, where he banged on it until it opened and exited the building. Staff reported that he left the building unsupervised, was later located several blocks away walking in the rain, and was brought back by staff in a car. The facility’s policy on elopements and wandering residents states that residents at risk for elopement will receive adequate supervision to prevent accidents and care in accordance with a person-centered plan of care, but R1 was able to leave the premises without necessary supervision.