F0689

D

Failure to Implement Fall-Prevention Interventions and Timely Call-Light Response

Country Club Hills, Illinois Survey Completed on 03-21-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement fall-prevention interventions and provide timely response to a call device for a resident identified as at risk for falls. On the morning of 03/20/2026, the call device monitoring screen at the nurses’ station showed that the call device in this resident’s room and bed had been activated for 24 minutes. A leaf symbol was displayed beside the resident’s name, indicating high fall risk. Despite the active call device, the resident was not in the room when checked and was later observed seated in a wheelchair across from the nurses’ station wearing gray pants that were not fully pulled up, with his incontinence brief visible.

The resident reported he had been waiting 30–40 minutes for staff to respond to his call device. He stated he became impatient, retrieved pants from his closet himself, and put them on without being able to pull them all the way up. He also stated he still needed help putting on socks and was wearing shoes without socks. The resident further reported that no one supervised him while he transferred himself using a sliding board and that no one assisted him in getting his pants from the closet. A CNA confirmed that the leaf symbol by the resident’s name signified fall risk and acknowledged that a resident should not wait 24–40 minutes for assistance, and that if the resident activated the call device, staff should have answered it so the resident would not attempt to get items independently.

Record review showed the resident had a history of stroke with hemiplegia affecting the left non-dominant side, contractures in both knees, and used a wheelchair as the primary mobility device. The MDS documented that he required partial/moderate assistance for lower body dressing. An OT discharge summary indicated he had achieved the goal of performing lower body dressing with supervision or touching assistance. The care plan documented that he had ADL self-care performance deficits related to hemiplegia, impaired balance, and limited ROM, used a sliding board for transfers, and required supervision for transfers with the sliding board. Another care plan focus identified him as at high risk for falls related to deconditioning, history of falls, and impulsive behavior, with interventions including reminding and encouraging him to call for assistance and keeping the call light within reach. Facility policies required timely response to call lights, development and implementation of a comprehensive care plan, and a fall prevention program with appropriate supervision and use of transfer devices. Despite these documented needs and policies, the resident’s call device was not answered promptly, and he transferred and dressed himself without required supervision, constituting the failure to implement fall-prevention interventions for a resident at risk for falls.