Essentia Health Homestead

interview on 3/31/26 at 2:14 p.m., NA-A stated R1 had received a shower and when she transported

when she wheeled R1 into her room she hit the doorframe with the right side of the wheelchair. NA-A

should have had the foot pedals on the wheelchair but had not put them on since she was only transporting R1 from the shower to her room. NA-A stated, following the incident, she received education related to following the care plan and was required to demonstrate transfers and transports more than once.During interview on 3/31/26 at 2:26 p.m., the director of nursing (DON) stated the care plan had not been followed when R1 had fallen.

The DON stated after the incident, education had been completed with NA- A and ongoing audits had been implemented to ensure safe transport and to ensure staff were following the plan of care.Facility policy Activities of Daily Living Standards of Care dated 9/10/25, indicated a plan of care was developed for each resident based on assessment, preferences, choices and standards of care.

All staff will be responsible for knowing and following the individual plan of care for each resident.

The Past Noncompliance began on 3/21/26 when NA-A was assisting R1 in her wheelchair from the shower room to R1's room without use of foot pedals. R1's wheelchair hit the door frame of R1's room.

This caused R1 to fall from her wheelchair which resulted in R1 sustaining a fracture, head injury and lacerations to her hand.

The deficient practice was corrected by 3/22/26, after the facility provided education to NA staff related to following the plan of care and developed and implemented audits to ensure care plan compliance and safe wheelchair transfers and transport.

The education was verified through interview and document review.