F0689

G

Failure to Supervise High-Risk Resident and Maintain Effective Fall-Prevention Measures

Chicago, Illinois Survey Completed on 03-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to adequately supervise and implement effective fall-prevention measures for a resident with a known history of falls and severe cognitive impairment. The resident had diagnoses including syncope, collapse, falling, transient cerebral ischemic attack, hypertension, abnormal gait and mobility, chronic fatigue, and Alzheimer’s disease. An MDS documented a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment, and showed the resident required supervision or touching assistance for toileting hygiene and walking 10 feet with a walker. The care plan identified the resident as at high risk for falls related to dementia, behavioral and mood disturbances, anxiety, poor awareness, decreased comprehension, impulsivity, and memory deficits, and documented that the resident required assistance with all ADLs, including toileting and walking, and demonstrated movement behaviors such as wandering, pacing, or roaming.

Despite these identified risks, the facility did not maintain accurate fall risk assessments or ensure consistent implementation of fall precautions. A fall risk assessment completed on the date of the fall scored the resident as high risk with a score of 13, but subsequent fall risk evaluations in December and January documented a score of 0, categorizing the resident as low risk for falls, which the DON later stated was not accurate. The resident’s orders allowed use of bed and chair alarms, and the care plan included use of a chair/bed alarm related to potential falls and frequent monitoring. However, staff interviews revealed uncertainty about whether the bed alarm was in place at the time of the fall, and one CNA reported that the bed alarm in use had a very faint sound, suggesting low battery, and could not be heard in the hallway. The DON stated that only residents at high risk for falls should have bed alarms and that any resident who has fallen is automatically considered high risk, indicating a discrepancy between policy and the documented low-risk scores.

On the day of the incident, the resident was found lying on his back on the bathroom floor with a laceration to the forehead after an unwitnessed fall. The resident reported having walked to the bathroom, used it, and then only remembered waking up on the floor. The resident did not have his walker with him in the bathroom at the time of the fall. Staff reported that the resident was impulsive, would get up by himself when he had the urge to use the bathroom, and required frequent monitoring and supervision when ambulating or going to the bathroom. The LPN and CNA assigned to the resident stated that he should have been supervised for toileting and ambulation and that if he had assistance with toileting, the fall could have been prevented. At the time of surveyor observation, the resident’s call light was found on the floor at the head of the bed, out of reach, despite staff acknowledging that the call light should always be within reach. Staffing on the unit consisted of one nurse and three CNAs for 38 residents, and both the DON and floor staff described this as a staffing problem that affected the ability to provide quality care and adequate supervision, contributing to the failure to prevent the resident’s fall and resulting head laceration requiring sutures.