F0689

D

Failure to Implement Fall-Prevention Interventions and Conduct Thorough Fall Investigations

Dwight, Illinois Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement required fall-prevention interventions and to conduct thorough fall investigations for two cognitively impaired residents. Facility policies required use of gait belts for all non-mechanical lift transfers and mandated that fall interventions be implemented and documented in the care plan, with residents observed every two hours and provided care as care planned. One resident with severe cognitive impairment and substantial/maximal assistance needs for bed mobility and transfers was care planned as a one-assist transfer. A fall report documented that this resident was lowered to the floor by a CNA and bumped her head on a trash can, but the facility’s fall investigation did not include an interview or statement from the CNA and did not document whether a gait belt was used. The documented root cause was weakness due to recent COVID-19 illness, and the only post-fall interventions noted were encouraging fluids and physical therapy. In a later interview, the CNA stated that the resident became weak during a wheelchair-to-bed transfer, that the CNA grabbed the waistband of the resident’s pants to lower her to the floor, and that a gait belt was not used even though it should have been for a one-person transfer. The DON stated that a gait belt should be used for all non-mechanical lift transfers and was unaware that one had not been used, and confirmed that the investigation documentation did not address gait belt use.

The second resident also had severe cognitive impairment, required partial/moderate assistance for transfers, and was always incontinent of urine and frequently incontinent of bowel. The care plan included interventions such as keeping the bed in a low position with a landing strip (fall mat) and a toileting plan that was later revised to include toileting every two hours and as needed. An unwitnessed fall report documented that this resident was found on the floor at the foot of the bed with a large skin tear and that the resident reported seeing a dog, going to look for it, and tripping over the floor mat; however, the fall investigation did not document when the resident was last checked or provided toileting/incontinence care. A subsequent unwitnessed fall documented the resident sitting on the floor between the foot pedals of the wheelchair, stating they were trying to put pants on, with the investigation again lacking documentation of when the resident was last checked or toileted. The root cause was listed as an attempt to self-toilet while on COVID-19 isolation, and the intervention was a revised toileting plan. During observations, no fall mat was present beside the resident’s bed despite the care plan calling for a landing strip when the resident was in bed. Staff interviews confirmed recent falls, incontinence at the time of one fall, reliance on the care plan for interventions, and that the fall investigations did not include staff statements or documentation of the timing of toileting or checks prior to the falls.