Rivaya Care Of Des Plaines

F 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

meet the res needs.Be sure the resident (Resident R1) call light is within reach and encourage the resident (Resident R1) to use it for assistance as needed. The resident (Resident R1) needs prompt response to all requests for assistance.Educate the resident (Resident R1)/family/caregivers about safety reminders and what to do if a fall occurs.Follow facility fall protocol.The resident (Resident R1) uses (specify: chair/bed) electronic alarm. Ensure the device is in place as needed. Resident R1's care plan interventions focused on his (Resident R1) education, reminders and use of call light when assistance is needed. However, Resident R1 is confused and forgetful. Resident R1's Progress notes dated 09/11/25 documented in part but not limited to the following: Resident R1 was observed up in chair, in no acute distress, eating breakfast, denies pain currently, alert and oriented to self, with noted confusion, requiring redirection per staff. On 09/25/25 at 1:19 PM, V2 (Director of Nursing) stated, He is a fall risk. He came from

the hospital because of a fall. He is alert, in and out, able to hold a conversation with you. He can tell you his needs and wants but detailed conversation and remembering things, not really. He needs to be redirected. He had a fall early in the morning, like at 1:30 AM, he got up and walked. His legs gave out when he was walking using the walker. It was unwitnessed fall, so he could not be redirected.Per admit evaluation note dated 09/11/25, Resident R1 uses a wheelchair due to gait disturbance and unsteady gait. Per care plan, Resident R1 uses electronic alarm, but was not implemented.On 09/25/25 at 10:46 AM, V13 (Nurse Practitioner) stated, Resident R1 is confused with place and time, he has dementia, able to verbalize needs. He sits

in the wheelchair. I have not seen him walk. He is a fall risk. Rounds/monitoring should be done; making sure bed is locked; wheelchair locked; wearing non-skid socks; and follow the facility fall protocol. Facility's policy titled, Falls Guideline, dated 8/2024 documented in part but not limited to the following:Purpose: To consistently identify and evaluate residents at risk for falls and those who have fallen to treat or refer for treatment appropriately and develop an organization-wide ownership for fall prevention to:To achieve each resident's maximum potential of physical functioning.To prevent or reduce injuries related to falls.To enhance residents' dignity and self-worth.The intent of this guideline is to ensure this facility provides an environment that is free from hazards over which the facility has control and provides appropriate supervision to each resident as identified through the following process:I. Identification of hazards and risksII. EvaluationIII. ImplementationIV. MonitoringV. AnalysisFall risk evaluation: a fall evaluation is used to identify individuals who have predicting factors for falls. This evaluation is completed upon admission, quarterly, annually and with a significant change in condition. Residents evaluated as at risk for falls will be identified and individualized fall precautions developed for each resident. Preventative measures shall be taken to decrease the number of falls whenever possible.Purpose:1. To consistently identify and evaluate residents who fall and to treat or refer for treatment appropriately.3. To prevent or reduce injuries related to falls.6. Individualize interventions for each resident.Evaluation may include: Residents with recent surgery or new admission; fall history; cognitive status1. If the evaluation finds the resident at risk, implement resident specific interventions/precautions.7. All residents identified as at risk for falls will be reviewed for individualized interventions.Fall Prevention is achieved through an IDT (interdisciplinary team) approach of managing predicting factors and implementing appropriate interventions to reduce risk for falls. Facility staff across all departments together with resident representatives and residents provide resourceful information with individualizing care and approaches.Understanding contributing and predicting factors that present will assist with determining individualized care approaches.Systems approach - Tips for Compliance:Involve interdisciplinary team (IDT) on: Individualized assessment for safety; identification of hazards; Development and implementation of interventions to reduce accidents.

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