F0689

G

Failure to Supervise High-Risk Resident in Wheelchair Leading to Fall and Head Injury

Miami, Florida Survey Completed on 03-18-2026

Penalty

No penalty information released

Summary

Staff failed to ensure a safe, supervised environment for a vulnerable resident at high risk for falls, resulting in a fall with major head injury. Video footage from the date of the incident showed a CNA escorting Resident #1, who was seated in a wheelchair, to the door of the auditorium. The CNA left the resident unattended at the doorway, did not lock the wheelchair brakes, and went inside the auditorium, leaving the resident outside without supervision. While the CNA was inside, the resident’s unlocked wheelchair began to roll until it contacted the sidewalk, at which point the resident fell from the wheelchair onto the pavement.

Nursing documentation from that day indicated that around the time of the incident, the resident was assessed near the auditorium and found with a laceration to the left forehead and significant bleeding, and was transported by ambulance to a hospital. Subsequent nursing notes and hospital records documented that the resident was diagnosed with a cerebral brain bleed, contusion and laceration of the cerebrum, and brain hemorrhage, and that the resident was admitted to the hospital and later returned to the facility. Clinical records showed the resident had diagnoses including fall from non-moving wheelchair, diffuse traumatic brain injury with loss of consciousness, dementia, functional quadriplegia, and left-hand contracture.

The resident’s records demonstrated a long-standing, documented high risk for falls, with multiple fall risk assessments over several years consistently indicating high fall risk and a fall history including several prior falls. The care plan, initiated and revised over time, identified the resident as high risk for falls related to history of falls, impaired mobility, difficulty communicating needs, unsteady gait, poor safety awareness, muscle weakness, left-sided weakness, psychotropic medication side effects, and overestimation of abilities, with interventions such as close supervision and encouraging the resident to remain in supervised areas when in a wheelchair. A recent MDS showed severely impaired cognition (BIMS score of 3/15) and a need for substantial/maximal assistance with transfers. After the incident, staff interviews confirmed that the CNA did not remember locking the wheelchair, acknowledged awareness that the wheelchair should be locked, and other staff reported that the resident required more assistance and had slower responses since returning from the hospital.