F0689

E

Failure to Implement Fall Interventions, Accurate Risk Assessments, and Thorough Fall Investigations

Danville, Illinois Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement and care plan fall interventions, accurately complete fall risk assessments, and thoroughly investigate falls for three residents. For one cognitively intact resident who required supervision/touch assistance for transfers and had an active care plan identifying fall risk and use of bed and chair alarms, fall risk assessments completed around the time of two falls incorrectly documented that the resident was not at risk for falls, was ambulatory, and used only 1–2 high‑risk medication classes. Medication administration records showed the resident was actually receiving multiple medications from the listed high‑risk classes. After two falls in which the resident attempted to self‑transfer to the bathroom and into bed, the fall investigations did not include staff statements identifying when the resident was last observed or toileted. An interdisciplinary note added bed and chair alarms as an intervention, yet surveyors observed the resident seated in a recliner without an alarm in place, and the CNA who assisted the resident into the recliner was unsure whether an alarm was required there.

Another resident with severe cognitive impairment, total incontinence, and a need for substantial/maximal assistance with transfers was found on the floor of a hallway bathroom after reportedly trying to go to the bathroom. A CT scan showed an L1 vertebral fracture. The fall investigation contained three staff statements, including one CNA who reported toileting the resident after lunch and then taking the resident to the dining room, but there was no documentation of whether the resident was observed after that time or whether any staff had transferred the resident onto the toilet and left the resident unattended. Staffing records showed multiple CNAs and nurses on duty at the time, but interviews with CNAs and an RN indicated they had last seen the resident in the dining room and were unaware the resident was in the hallway bathroom. Nursing documentation noted the resident had a chair alarm, but the active care plan did not include chair alarm use, and the DON later confirmed there was no documentation of bed or chair alarms in the record prior to the recent fall despite staff reporting alarm use.

A third resident with moderate cognitive impairment, total incontinence, and dependence on staff for toileting and transfers had a care plan addressing incontinence with frequent checks and changes, but fall risk assessments incorrectly documented that the resident received only one or two medications from high‑risk drug classes. Medication records showed the resident was actually receiving several medications from those classes. The resident experienced an unwitnessed fall in the room, where the resident was found on the floor on a fall mat after reportedly attempting to get out of bed due to seeing children; the fall investigation did not document staff interviews or when the resident was last checked or toileted. A subsequent witnessed fall occurred when a CNA, present for the roommate, saw the resident slipping out of bed and braced the resident to the floor on the mat; again, the investigation did not document when the resident was last checked or toileted. The DON confirmed that the fall investigations for this resident lacked documentation of last checks or toileting and that the fall risk assessments did not accurately reflect the resident’s medications.