The incident at Woodside Village unfolded over several minutes on the morning of November 5th. CNA #1 wheeled Resident #7 to the dining room at 7:50 AM and left him at a table with the wheelchair foot pedals still attached.
The aide then walked down the hall to retrieve garbage from the resident's room. On his way to dispose of it, he stopped to speak with a registered nurse about a sticker on the wheelchair pedals that read "pedals stay on at all times."
The nurse clarified that the pedals should be removed when residents are stationary. But instead of returning to remove them, CNA #1 continued to the utility room to throw away the garbage.
As the aide walked back toward the dining room, Resident #7 stood up from the wheelchair and fell backward, hitting his head on a dining room chair.
The wheelchair had been left in Resident #7's room after he returned from hospitalization for pneumonia the previous day. His care plan, dated November 4th, specified he needed assistance from one person with a gait belt for walking.
Facility policy stated foot pedals should be used during transport over extended distances but removed when wheelchairs are stationary, unless specifically required by a resident's care plan.
The registered nurse immediately assessed Resident #7 after the fall. The facility completed an investigation, notified his primary decision maker and physician, and reported the incident to the Department of Health and Human Services.
Staff received education about wheelchair foot pedal policies the same day as the incident. The facility also began conducting wheelchair positioning audits.
CNA #1 was terminated on November 11th, six days after the fall.
In his written incident report, the aide acknowledged seeing the confusing sticker about keeping pedals on at all times. He also documented asking the nurse for clarification about the policy.
But federal inspectors found the aide failed to follow through on the nurse's instruction to remove the foot pedals before leaving Resident #7 unattended in the dining room.
The inspection report noted that removing the wheelchair foot pedals was necessary to prevent accidents. Failure to do so may have contributed to the resident's fall.
Resident #7 had just returned from the hospital the day before the incident. The wheelchair remained in his room from the transport back to the facility.
The facility's Standards of Care policy, dated October 6th, clearly outlined when foot pedals should be used and removed. The policy specified pedals were for extended transport distances and should be removed when wheelchairs are stationary, unless a resident's individual care plan required otherwise.
Inspectors reviewed Resident #7's care plan and found no specific requirement for keeping the foot pedals attached while he was seated at the dining table.
The investigation revealed a breakdown in communication and follow-through. While CNA #1 sought clarification about the conflicting sticker, he failed to act on the nurse's clear instruction before leaving the resident alone.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. They determined the facility had implemented immediate corrective actions following the incident.
The corrective measures included staff education, policy clarification, ongoing monitoring audits, and the termination of the aide responsible for the safety lapse.
Resident #7 was monitored for signs of injury, distress, or changes in condition following the fall. The facility's investigation was completed the day after the incident occurred.
The case illustrates how seemingly minor oversights in following safety protocols can lead to preventable accidents in nursing homes, even when staff members recognize potential policy conflicts and seek guidance.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Woodside Village from 2025-12-22 including all violations, facility responses, and corrective action plans.