Ness County Hospital Ltcu Dba Cedar Village

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

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

the floor, which caused her to fall forward out of her wheelchair onto the floor. Administrative Nurse E looked down the hall, saw Resident R1 on the floor in front of her wheelchair, and went to assist. Resident R1 sustained a laceration to her forehead, staff applied pressure, and the bleeding stopped. The staff assisted Resident R1 off the floor and back into her wheelchair after foot pedals were placed, and then transferred Resident R1 to the emergency room for evaluation. The primary care provider evaluated Resident R1 in the emergency room. The laceration was cleansed and sutured, requiring eight sutures. A computed tomography (CT scan- a test that used X-ray technology to make multiple cross-sectional views of organs, bone, soft tissue, and blood vessels) scan of

the head was completed, and the findings showed a small frontal scalp hematoma. Resident R1 returned to the facility and was monitored per protocol. Sutures were expected to be removed in seven days. Resident R1 had dementia and behaviors, liked to propel herself down the hall, and did not like the pedals on the chair. The investigation documented every resident in a wheelchair would have pedals on their wheelchair or in their room so they could be placed on the wheelchair when necessary. All staff would be educated on this change. Administrative Nurse D and Administrative Nurse E would monitor to ensure this was occurring.

The Facility Risk Management Summary, dated 10/01/25, documented on 09/12/25 at 03:00 PM, Resident R1 propelled herself down the hallway, followed by LN G when Resident R1 abruptly put her feet onto the floor, which caused Resident R1 to fall forward out of her wheelchair onto the floor. Administrative Nurse E looked down the hall and saw Resident R1 on the floor in front of her wheelchair. Resident R1 sustained a laceration to her forehead. Pressure was applied, and bleeding stopped. Resident R1 was assisted off the floor and into her wheelchair by three staff members and taken to the emergency room to be evaluated. Facility recommendation for foot pedals to be placed on all wheelchairs and flipped up when residents want to propel themselves down the hall.On 10/20/25 at 10:30 AM, observation revealed Resident R1 lay in bed and tossed and turned, appearing restless. A wheelchair was not seen in Resident R1's room. The injury to Resident R1's head had healed.On 10/20/25 at 11:30 AM, observation revealed several residents sitting in a music activity in the activity room. None of the wheelchairs had foot pedals present.On 10/20/25 at 11:45 AM, LN G stated she did not normally work on the floor, and the day Resident R1 fell,

she went out to help staff provide one-on-one with Resident R1. LN G stated Resident R1 was all over the place and tried to crawl out of the recliner by the nurse's station. LN G stated Resident R1 was placed in her wheelchair, and Resident R1's wheelchair did not have foot pedals on. LN G stated R1was moving down the hall by pulling herself on the handrail. LN G stated she would nudge her along occasionally and keep her from going into others' rooms.

LN G stated the fall happened so fast there was nothing she could do to prevent it.On 10/20/25 at 11:50 AM, Administrative Nurse E stated the only education given to staff was on a Weekly Case Management sheet, the facility used to provide staff with education/information. Staff were told the intervention for Resident R1's fall was to ensure the foot pedals were on her wheelchair when pushing Resident R1 in her wheelchair.On 10/20/25 at 12:15 PM, Administrative Nurse D stated the facility had not provided any education to staff regarding ensuring foot pedals were on wheelchairs. Administrative Nurse D stated foot pedals should be on residents' wheelchairs to ensure they were readily available to use. Administrative Nurse D stated an audit was performed after Resident R1's fall for all of the residents who used wheelchairs to ensure they all had foot pedals.The facility's Fall Risk Assessment Policy, revised 05/12/20, documented residents would be evaluated for the potential risk of falling, and appropriate measures would be taken to reduce or eliminate those risks. Staff will seek to identify environmental hazards that may contribute to falls. Interventions to prevent/minimize falls would be added to the residents' care plan. Staff would collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors.

Event ID:

Facility ID:

17E625

If continuation sheet