F0689

D

Failure to Supervise High Fall-Risk Resident During Transfer

Lansing, Illinois Survey Completed on 03-13-2026

Penalty

No penalty information released

Summary

The facility failed to ensure adequate supervision and monitoring during a transfer for a resident with a known history of falls and multiple risk factors. The resident had diagnoses including dementia, Parkinson's disease, edema of both lower extremities, unspecified abnormalities of gait and mobility, and was identified as high risk for falls. The resident’s care plan dated 2/13/2026 indicated the need for a sit-to-stand mechanical lift for transfers due to decreased lower extremity strength and endurance, with interventions to maintain body alignment and ensure safe placement of extremities during transfers. Despite this, on 3/3/2026 a CNA sat the resident on the side of the bed and left to retrieve the mechanical lift, during which time the resident began to slide and was subsequently lowered to the floor.

Interviews and record review confirmed that the resident had multiple prior falls, including an unwitnessed fall from bed on 12/21/2025 and a fall on 1/23/2026 when the resident attempted to go to the bathroom independently. On 3/10/2026, the resident reported that he was unable to maintain his balance when left sitting on the side of the bed and slid to the floor. On 3/11/2026, the CNA stated she had left the resident seated at the bedside to get the mechanical lift and returned when he yelled, then lowered him to the floor and sought assistance. On 3/12/2026, the Restorative Nurse/Fall Coordinator stated that the resident was high risk for falls and should not be left alone on the side of the bed, and the DON stated that staff are expected to monitor any high fall-risk resident and never leave them alone on the side of the bed. The facility’s Falls-Clinical Protocol identified history of falls and gait and balance disorders as risk factors for subsequent falls.