F0689

D

Failure to Ensure Wheelchair Safety and Proper Gait Belt Use Resulting in Resident Falls

Aviston, Illinois Survey Completed on 01-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision to prevent accidents for two residents, both in relation to wheelchair safety and transfer/ambulation assistance. One resident with severe cognitive impairment, dementia, bipolar disorder with psychotic features, schizoaffective disorder, seizure history, and prior falls used a manual wheelchair and required substantial to maximal assistance for wheeling 50–150 feet, along with maximum verbal and tactile cues due to low comprehension and confusion. The resident’s care plan identified risk for falls and injuries related to weakness, dementia, and poor safety awareness, with interventions including use of proper assistive devices and cueing/redirection as needed. The facility’s wheelchair safety policy required staff to ensure proper foot placement on footrests and safe use and supervision of wheelchairs.

On one occasion, a CNA was asked to return this resident from a hallway where the resident was known to go in an attempt to get into other residents’ beds. The CNA began pushing the resident in the wheelchair back toward the nurse’s station without foot pedals in place. Multiple staff, including the CNA, LPN, and DON, reported that the resident’s feet were not on footrests and that the resident put her feet down while being pushed, causing a foot to become caught in the wheelchair wheel. This resulted in the resident falling forward out of the wheelchair and striking her head on the floor, reopening a previous forehead laceration and causing additional injury to the elbow. The facility’s event report documented that the resident’s foot became caught in the front wheel while being pushed in the hallway, leading to the forward fall.

The second resident had diagnoses including cerebral infarction, COPD, asthma, hypertension, seizure disorder, depression, anxiety, and osteoarthritis, and was cognitively intact with a BIMS score of 14. The MDS and therapy staff documented that this resident required partial/moderate assistance with self-care and mobility and had episodes of being unbalanced and falling backward when ambulating. The resident’s care plan identified a need for assistance with ADLs due to weakness and a risk for falls and injuries, with an intervention to observe for safety. The facility’s gait belt policy required use of gait belts when transferring weight-bearing residents or assisting them with walking.

Despite this, a CNA responded to the resident’s call light for toileting assistance and helped the resident ambulate with a walker from a recliner to the bathroom without using a gait belt. During ambulation, the resident became off balance, which the CNA stated happens at times, and the CNA grabbed the resident’s shirt and pants on the left side to guide the resident to the floor. The resident ended up sitting on the bathroom floor with her back against the door and was then assisted by two CNAs to the toilet and back to the recliner. Both the CNA and the resident later confirmed that no gait belt was used during the transfer or ambulation. Several days later, an LPN noted the resident’s complaints of left shoulder pain, bruising, and limited movement, and imaging ordered by the practitioner showed a left shoulder separation and arthritis. The DON and Administrator stated that facility policy and their expectations required use of a gait belt during transfers and ambulation, and the fall management policy defined such an event, including a loss of balance that would have resulted in a fall without staff intervention, as a fall.