Ness County Hospital Ltcu Dba Cedar Village

wheelchair after foot pedals were placed, and then transferred R1 to the emergency room for

cleansed and sutured, requiring eight sutures. A computed tomography (CT scan- a test that used

vessels) scan of the head was completed, and the findings showed a small frontal scalp hematoma.

R1 returned to the facility and was monitored per protocol.

Sutures were expected to be removed in seven days. 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, R1 propelled herself down the hallway, followed by LN G when R1 abruptly put her feet onto the floor, which caused R1 to fall forward out of her wheelchair onto the floor.

Administrative Nurse E looked down the hall and saw R1 on the floor in front of her wheelchair.

R1 sustained a laceration to her forehead.

Pressure was applied, and bleeding stopped. 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 R1 lay in bed and tossed and turned, appearing restless. A wheelchair was not seen in R1's room.

The injury to 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 R1 fell, she went out to help staff provide one-on-one with R1. LN G stated R1 was all over the place and tried to crawl out of the recliner by the nurse's station. LN G stated R1 was placed in her wheelchair, and 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 R1's fall was to ensure the foot pedals were on her wheelchair when pushing 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 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.