F0689

D

Inaccurate Fall Risk Assessment and Lack of Assisted Ambulation for High-Risk New Admission

Chicago, Illinois Survey Completed on 03-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to complete an accurate fall risk assessment and to identify a newly admitted resident as high risk for falls, despite a documented history of falls, unsteady gait, and dementia with confusion. The resident’s diagnoses included polyneuropathy, peripheral vascular disease, hypertension, dementia, osteomyelitis of the left ankle and foot, and cellulitis of the left lower limb. Hospital physical therapy records used by the facility documented that the resident required a gait belt, 2-wheeled walker, and at least contact guard to minimal assist for transfers and ambulation, with noted unsteady gait, decreased cadence and step length, heavy reliance on upper extremities, narrow base of support, and impaired balance, cognition, strength, and safety awareness. The nurse-to-nurse report from the hospital also indicated dementia, confusion, forgetfulness, and a need for +1 assist with mobility. The admitting RN’s assessment documented the resident as confused and forgetful, alert and oriented only x1–2, requiring partial/moderate assist with transfers, and that walking was not attempted due to medical or safety concerns.

Despite this information, the facility’s fall risk assessment completed after the fall documented that the resident was not at risk for falls and had no history of falls, and that no fall interventions were in place prior to the incident. The DON stated that the fall risk assessment for a new admission is expected to be completed within four hours of admission to establish a baseline for the plan of care and that, hypothetically, a resident who had fallen in January and was admitted in February would be considered a fall risk. The DON also stated that the fall assessment for this resident was considered accurate based on the history that the resident had a fall in the past, even though the post-fall investigation form indicated “No” for history of falls and “No” for being at risk for falls. The resident’s inventory did not identify a walker, and the DON did not know where the walker used at the time of the fall came from. The fall coordinator explained that a history of falls reported by family would identify a resident as a fall risk and that the facility has a fall risk assessment and interventions such as floor mats and alarms, but there is no indication these were implemented for this resident.

Interviews with staff and the resident’s wife further described the circumstances leading to the fall. The RN on duty reported being told at shift report that the resident was a fall risk and used a walker, and that the resident was alert and oriented x2–3. The RN stated that the resident was new, had some confusion, was getting up frequently, and did not use the call light. The RN assisted the resident with toileting about an hour before the fall and later observed the resident ambulating alone in the hallway with a walker, wearing non-skid socks and a gown, and then attempting to turn by lifting the walker, losing balance, and falling onto his buttocks and hitting his head. A CNA reported seeing the resident get himself up from bed and walk toward the nurse’s cart before the fall, and that the other CNA assigned to the floor was not in the area at the time. The resident’s wife reported that the resident had fallen several times at home, including off the toilet, and that in the hospital he had bed and chair alarms. She stated that a full-time caregiver informed a group of staff at the desk that the resident was at risk for falls and had alarms in the hospital, and that staff responded they could not implement alarms until he was assessed the next day. She also reported that no one from the facility called her for history or questions during admission and that the resident was placed in a room several rooms away from the nurses’ station. The incident and change in condition forms documented the fall time as 3:10 a.m., while the post-fall investigation documented 4:10 a.m., indicating a discrepancy in the recorded time of the event.

The post-fall investigation’s root cause analysis stated that the resident, admitted within 24 hours and baseline alert/oriented x1, lifted his walker in an attempt to turn, lost balance, and fell on his buttocks, then hit his head. The RN reported that the resident was on a blood thinner (Xarelto), hit his head, and was sent to the hospital by 911. The DON confirmed that the resident had wounds on the left ankle and a healed amputated toe on admission and that the resident did not return to the facility after transfer to the hospital. Staff interviews confirmed that CNAs are issued gait belts at hire and trained in their use, and that extra gait belts are available at nurses’ stations, but the report does not document that a gait belt or one-person assist was used when the resident was ambulating independently in the hallway at the time of the fall. The combination of inaccurate fall risk assessment documentation, failure to recognize and document the resident’s history of falls and need for assistance, and lack of implementation of fall interventions contributed to the resident ambulating alone and experiencing a fall with head impact shortly after admission.