F0689

G

Resident Left Unattended in Wheelchair Contrary to Care Plan, Resulting in Fall

Platte, South Dakota Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The deficiency involves a failure to ensure a resident’s care plan was followed to prevent accidents. A certified nursing assistant (CNA) who primarily worked in activities transported a resident back to his room in a wheelchair after an activity and left him alone in the room with his call light within reach. The resident’s pocket care plan, which the CNA had but did not read, clearly stated in bold print that he could not be left alone in his wheelchair in his room. At the time, the CNA was a newer employee who had recently passed her CNA test and did not usually work CNA shifts, and she reported she was not aware of the resident’s care plan requirement that he not be left unattended.

After being left alone, the resident attempted to adjust his pants and transferred himself toward the toilet. During this attempt, his right leg gave out, and he slid down in his wheelchair onto the foot pedals. He then pulled the bathroom call light for assistance. When staff responded, he reported increased pain in his right leg and an inability to bear weight on that leg. He rated his pain as 10 out of 10 and was subsequently sent to the emergency department for evaluation.

At the emergency department, X‑rays of the resident’s right thigh and pelvis showed no acute findings, meaning there were no fractures. Following his return, additional pain control measures were ordered, including PRN acetaminophen, topical diclofenac gel, and a lidocaine patch for his right thigh. The resident used the lidocaine patch daily until it was discontinued at his request several days later. Later review of his pocket care plan showed the instruction “DO NOT LEAVE ALONE IN WHEELCHAIR IN HIS ROOM!!!!!” in bold letters, confirming that the resident-specific fall prevention intervention was in place but not followed at the time of the incident.