F0689

D

Failure to Implement Fall Prevention Interventions for High-Risk Resident

Prospect Heights, Illinois Survey Completed on 12-12-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement fall prevention interventions for a resident with a documented history of multiple falls and high fall risk. On two separate observations, the resident was seen sitting in a wheelchair in her room, alert but with impaired hearing and slurred speech, and with the call light placed out of her reach. During both observations, the DON confirmed that the call light should have been accessible and within the resident’s reach for safety. The resident’s care plan interventions specified that staff should assist the resident to meet needs and maintain safety, including keeping the call light and personal effects within easy reach.

Record review showed that the resident was admitted with diagnoses including history of falling, displaced trimalleolar fracture of the left lower leg, closed fracture with routine healing, subluxation of the left ankle joint, muscle weakness, muscle wasting, unsteadiness on feet, and hearing loss. The comprehensive care plan identified the resident as being at risk for falls related to history of falls and weakness, and the most recent fall assessment documented that the resident was at high risk for falling. The resident had a witnessed fall on one date, where she slid from her wheelchair while leaning forward to pick up a tissue, and an unwitnessed fall on a later date, after which she was sent to the hospital for evaluation. For the second fall, the root cause analysis was documented as a copy of the previous incident report, rather than a newly developed analysis, despite facility policies requiring identification of underlying causes, review of current interventions, and updating the care plan with new interventions after each fall.