Accolade Healthcare Danville

R1's limited ability and the physical therapist assistant completing therapy on 10/31/25 should have had another person with her due to R1's limited mobility in bed. On 11/4/2025 at 11:35 AM, V6 Physical Therapist Assistant (PTA) stated she was completing therapy with R1 on 10/31/25. V6 stated V6 asked R1 to sit on the side of the bed and had a walker in front of R1 to help stabilize R1. V6 stated R1 is dependent with bed mobility and does not stand. V6 stated she had R1 sitting on the side of the bed, but stated R1 was on the edge of the bed. V6 stated she let go of R1 and was walking to the other side of the bed to try to pull R1 into the middle of the bed when R1 fell forward off the bed and hit the bedside table. R1 fell forward face first. V6 stated before the therapy session started V6 looked outside of the room to see if anyone was available and didn't see anyone so went to work with R1. On 11/5/2025 at 9:37AM, V9 Licensed Practical Nurse (LPN) stated the physical therapist assistant (PTA) came and got her that night and stated there was blood all over the floor. V9 stated she immediately called 911. V9 stated the PTA never asked for assistance with R1. V9 stated due to R1's weight, and needing maximum assistance, the PTA should not have started the therapy session until someone was available to help balance R1. On 11/5/2025 at 11:05AM, V2 Director of Nursing (DON) stated V6 (PTA) should have had two people working with R1 for safety concerns as R1 is dependent and needs help with bed mobility, transfers and dressing. V2 stated V6 (PTA) should have waited to complete the therapy session until somebody could help her. V2 stated that the lack of safety concern and not having two people in with R1 resulted in the fall which caused R1 to need emergency medical treatment and including 14 staples to her head. On 11/4/2025 at 12:45 PM, V10 (R1's Nurse Practitioner) stated R1 has had a decline since R1 was admitted from the last stay. V10 stated R1 has limited mobility and is completely dependent on staff while rolling side to side. R1 also needs maximum assistance with activities of daily living, V10 stated, because R1 requires maximum assistance and weighs 343 pounds. V6 PTA needed someone else to assist with R1 while completing therapy to provide a safe therapy session. V10 stated that R1 is alert and orientated and the therapist walked away from R1 without holding onto R1.The Facility's Safety Policy revised on 9/23 documents that the staff will support the resident's body well during all positioning, transferring and ambulation.

Avoid pulling on the resident's extremities.

Provide two or more persons to assist when necessary for resident and staff safety.

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