Failure to Use Wheelchair Footrests During Transport Resulting in Resident Fall and Injury
Penalty
Summary
The facility failed to follow its wheelchair transport policy requiring the use of footrests during transport, resulting in a resident fall and injuries. The written policy dated January 8, 2026, specified that footrests must be used when staff, family, volunteers, and healthcare partners transport residents in wheelchairs, Broda chairs, or other chairs with attachable footrests to prevent accidents and injuries. Resident 1’s annual MDS assessment dated February 13, 2026, documented that the resident was cognitively impaired, required staff assistance for daily care needs, and had dementia among other diagnoses. On December 20, 2025, at approximately 10:40 p.m., Nurse Aide 1 was pushing Resident 1 in a wheelchair without leg rests in place when the resident leaned forward and fell to the floor. The incident investigation and witness statement from Nurse Aide 1 confirmed that the resident did not have leg rests on the wheelchair at the time of transport and that the resident leaned forward and fell out of the wheelchair. As a result of the fall, Resident 1 sustained a 1.5 by 1.5-centimeter abrasion to the left side of the forehead, a 0.5 by 0.5-centimeter abrasion to the left eyebrow, and a 3 by 3-centimeter bruise to the left side of the forehead. In an interview, the Nursing Home Administrator confirmed that leg rests should have been in place when transporting this resident, indicating noncompliance with the facility’s resident care policies and nursing services requirements under 28 Pa. Code 211.10(c)(d) and 211.12(d)(5).
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.