F0689

D

Failure to Implement Fall Prevention Interventions for High-Risk Resident

South Holland, Illinois Survey Completed on 03-21-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement fall prevention measures for a resident identified as high risk for falls. The resident is an older adult with multiple diagnoses including cerebral infarction, aphasia, dysphagia, essential and secondary hypertension, hyperlipidemia, anemia, osteoporosis, insomnia, a right artificial hip joint, dementia, depression, a history of falling, low back pain, and a personal history of urinary tract infections. Fall risk reviews dated 9/25/25 and 2/28/26 identified the resident as high risk for falls. The care plan for risk of falls, in place since 1/1/24, included an intervention to ensure the resident is wearing appropriate footwear, specifically non-skid socks or other described proper footwear, when ambulating or mobilizing in a wheelchair.

On 2/28/26, a facility-reported incident documented that staff found the resident sitting on the left side of the bed between the dresser and the bed after an apparent self-transfer from bed without assistance. The resident denied pain, was able to move all extremities, and had all limbs in good alignment, but staff noted gait imbalance and unsteadiness, and a small hematoma to the right side of the face with bruising. The incident occurred in the context of the resident’s known confusion, unawareness of safety needs, unsteady gait, impulsiveness, and history of falls, which were identified in the care plan as contributing factors to the resident’s fall risk. A care plan intervention dated 2/28/26 also specified moving furniture away from the bed as part of fall prevention.

On 3/21/26, surveyors observed the resident sitting in a wheelchair without shoes and wearing regular socks instead of non-skid socks, and the room setup showed the bed positioned next to furniture (nightstand/dresser) on the left side of the bed. An LPN stated that the resident should have non-skid socks as a fall intervention but was unsure about the bed and furniture arrangement as an intervention. A CNA reported that she had dressed the resident and did not put on the non-skid socks, stating there was no particular reason for not doing so. The DON and Administrator both stated that their expectation is for staff to follow and implement all fall interventions for high-risk residents and that interventions are available in the resident’s point-of-care chart and communicated by restorative staff. Despite the facility’s written fall prevention policy requiring implementation of individualized interventions and monitoring of proper non-skid footwear, the resident’s care plan interventions regarding footwear and room furniture arrangement were not consistently implemented at the time of surveyor observation.