F0689

G

Obstructed Platform Scale Access Leads to Resident Fall and Head Laceration

Westfield, Massachusetts Survey Completed on 03-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a safe, hazard‑free environment and provide adequate supervision during the use of a wheelchair‑accessible platform scale. The facility’s own Safety and Supervision of Residents policy stated that the environment should be as free from accident hazards as possible and that resident safety, supervision, and assistance to prevent accidents are facility‑wide priorities. Despite this, the dual‑ramp platform scale in the Unit B shower room was positioned lengthwise against a wall, with one ramp obstructed by the back wall, the back of the platform against the left wall, and the front of the platform blocked by a very large shower bed. This left only the left‑side ramp accessible to residents and staff, significantly limiting staff’s ability to position themselves around the scale to safely assist residents.

The resident involved was admitted in June 2023 with diagnoses including dementia with agitation and unspecified osteoarthritis. A quarterly MDS dated 11/06/25 documented that the resident was severely cognitively impaired, with a BIMS score of 3/15, and required substantial assistance from staff for transfers and ADLs. On the day of the incident, a CNA, who had been working regularly at the facility through an agency for about a year and was familiar with the scale, weighed the resident in the wheelchair‑accessible platform scale. To position the resident, the CNA stood behind the wheelchair and pulled the resident up the small left‑side ramp. Once the wheelchair was on the platform, the CNA was confined against the wall on the right side of the scale, with the shower bed obstructing the long edge of the scale, limiting her ability to maneuver around the resident.

After obtaining the resident’s weight, the CNA attempted to push the wheelchair down the left‑side ramp to exit the scale. During this maneuver, the resident abruptly lowered a foot and leaned or tipped forward. Due to the obstructions and limited space around the scale, the CNA was unable to move quickly around to the front of the wheelchair to provide adequate physical assistance. The resident fell forward out of the wheelchair onto the floor, striking the head and sustaining a forehead laceration. Nursing staff responding to the incident found the resident on the floor in front of the wheelchair near the left side of the scale, with a forehead laceration and bruising later documented on the forehead, under both eyes, and on the left hand. The resident was sent to the ED, where the injury was diagnosed as an acute forehead laceration from a mechanical fall and closed with five sutures. The DON later stated she was unaware that the shower bed was stored in the Unit B shower room or that it limited staff’s ability to navigate around the scale.