F0689

G

Failure to Maintain Wheelchair Footrest Interventions Resulting in Repeat Fall With Head Injury

Decatur, Georgia Survey Completed on 01-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement and maintain fall-prevention interventions for a resident with known cognitive impairment and prior fall history, as required by its Fall Prevention Program policy. The policy directed that after any fall, the facility must assess the resident, complete a post-fall assessment and incident report, notify the physician and family, review and update the care plan as indicated, and document all assessments and actions. Following a fall on 9/19/2025 in which the resident leaned forward, fell while being taken to the dining room, and hit their head, the incident report documented that the resident sustained a forehead bruise, vital signs were taken, and family was notified. The documented intervention after this fall was that staff were to ensure the resident was fully back in their wheelchair with feet on the footrests and clothing/shoes adjusted before transport began.

The resident, who had Alzheimer’s disease, moderate cognitive impairment, short- and long-term memory problems, and used a wheelchair, had a documented history of a fall with major injury since the prior MDS assessment and a diagnosis of nontraumatic intracranial hemorrhage. On 10/28/2025, a post-fall record and exception report indicated that the resident slid out of their wheelchair to the floor and hit their head while being transported from the cafeteria to their room after lunch, resulting in a laceration, swelling, bruising, and a hematoma above the right eye. The resident was sent to the hospital, where records showed a laceration of the head, nontraumatic intracranial hemorrhage, and nontraumatic subarachnoid hemorrhage, with CT imaging revealing a trace subarachnoid hemorrhage and documentation that the resident was critically ill and required ICU-level monitoring.

Staff interviews revealed that on the day of the 10/28/2025 fall, the CNA pushing the resident from the dining room stated the resident’s legs were straight out about five inches off the floor and that there were no footrests on the wheelchair at the time of transport. This CNA stated she noticed there were no footrests only after the fall, and that footrests should have been present. Another CNA, who had gotten the resident up and taken them to the dining room earlier, stated she thought the footrests were on the wheelchair when she transported the resident to the dining room, but acknowledged that sometimes the wheelchair had footrests and sometimes it did not, and that footrests should have been on before transport. The LPN who responded to the fall stated she had told the CNA to make sure the footrests were on before taking the resident to the dining room and suggested that someone may have removed them in the dining room so the resident’s legs could fit under the table, but confirmed they should have been put back on before transporting the resident. The DON and Administrator both stated that all interventions, including footrests, should have been in place before transporting the resident, indicating that the required fall-prevention intervention of using footrests during wheelchair transport was not consistently implemented at the time of the fall.