Unsafe Shower Chair Transfers and Ineffective Brakes Leading to Resident Fall and Head Injury
Summary
The deficiency involves the facility’s failure to ensure safe transfers and prevent accidents during use of shower chairs and wheelchairs, resulting in a serious fall with head injury for one resident and unsafe transfer practices for others. One resident with diagnoses including atrial fibrillation, dementia, chronic kidney disease, obesity, sequelae of cerebral infarction, diabetes mellitus type 2, hypertension, and osteoarthritis was care planned as at risk for falls and required partial/moderate assistance for transfers. During a transfer from a shower chair to a wheelchair after a shower provided by a CNA, the resident reported asking if both the shower chair and wheelchair were locked and being told they were. The resident stated she placed her hands on the arms of the shower chair, began to stand, and the shower chair moved backward; she was unable to sit back down and fell to the floor, striking her head. She reported that the CNA was in front of her near the wheelchair rather than behind the shower chair securing it, and that in the past staff had held the back of the shower chair during transfers. Hospital documentation following this event described a mechanical fall while the resident was getting out of the shower chair when it slipped, causing her to strike her head, with imaging showing a possible 2–3 mm subarachnoid hemorrhage and a minimal parieto‑occipital hematoma. Facility staff interviews provided differing accounts of the transfer mechanics but consistently indicated that the resident was transferring from the shower chair to the wheelchair when the incident occurred. The CNA involved stated he locked both the shower chair and wheelchair, that the resident declined assistance and transferred independently, and that she became weak, sat on the edge of the shower chair seat, and the back of the chair raised and tipped forward. The facility’s incident note documented that the CNA reported holding the wheelchair while the resident transferred and that one of the shower chair wheels came out, causing her to lose balance and fall. Nursing leadership interviews reflected conflicting recollections of whether the resident was holding the shower chair armrests or the wheelchair armrests at the time of the fall, but confirmed that the shower chair moved and that a wheel was reported to have come off. Further observations and staff interviews revealed that the plastic‑caster shower chairs used in the facility did not remain stationary even when their brakes were applied, and that staff were aware they could slide or roll on tile floors. Direct testing of the shower chairs showed that with the brakes locked, the chairs could still be propelled or rolled on the tile floor. A maintenance director initially stated he had no concerns about the brakes and that CNAs knew they had to hold the shower chairs because they slide on tile regardless of brake use, later acknowledging that the wheels did turn despite the brake mechanism being applied. An LPN and CNA demonstrated that locked shower chair wheels could roll when pushed, and another CNA stated she did not rely on the brakes, instead using her own strength to hold the chair and at times moving a shower chair and positioning a wheelchair for a resident without locking the wheelchair brakes before seating the resident. In another observed transfer, a cognitively intact resident who required only setup or cleanup assistance was able to pull a locked‑brake shower chair toward himself and cause it to slide backward as he sat, and was then transported down the hall with the shower chair brakes still locked while the wheels continued to roll. These observations occurred in the context of a facility transfer policy that required stabilizing or locking all surfaces, including wheelchairs and beds, and prohibiting residents from pulling up on assistive devices to achieve standing, indicating that the transfer practices and equipment performance did not align with the written policy. The residents involved in these events had significant medical and functional conditions relevant to safe transfers. The resident who fell and sustained a head injury had intact cognition per MDS but multiple comorbidities including prior cerebral infarction, morbid obesity, and dependence on renal dialysis, and was care planned as at risk for falls. Another resident had dementia, unsteadiness on feet, abnormal gait and mobility, lack of coordination, and weakness, and required supervision/touching assistance for all transfers; during an observed shower transfer, his shower chair rolled slightly back when he stood because the CNA was holding his incontinence brief and not securing the chair, and the CNA acknowledged that most shower chair brakes were not solid and that she did not put faith in them. A third resident with Parkinson’s disease with dyskinesia, bipolar disorder, anxiety, congestive heart failure, cardiomegaly, osteoarthritis, and prior cerebrovascular events was cognitively intact and required only setup or cleanup assistance for transfers, yet was able to move a locked‑brake shower chair toward himself and cause it to slide during transfer. Across these cases, the combination of shower chairs whose wheels rolled despite engaged brakes, staff reliance on physical strength rather than reliable braking mechanisms, and failure to consistently secure both the shower chairs and wheelchairs during transfers contributed to unsafe transfer conditions and the cited deficiency. The facility’s own transfer policy specified that all surfaces, including wheelchairs and beds, must be stabilized or locked, and that residents should push up from wheelchair armrests and not pull up from assistive devices to achieve standing. However, the observed practices showed residents pulling on shower chair armrests and moving chairs with brakes applied, staff not always locking wheelchair brakes before seating residents, and staff acknowledging that they did not rely on shower chair brakes because they allowed movement on tile floors. The facility was unable to provide a manufacturer’s instruction manual for the shower chairs in use, and staff interviews indicated awareness that the chairs could slide even when brakes were engaged. These documented actions, inactions, and equipment conditions formed the basis of the deficiency for failing to ensure the environment was free from accident hazards and that adequate supervision and safe transfer practices were provided to prevent accidents.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Unsafe Cord Placement and Failure to Follow Fall Interventions: A resident with cognitive impairment and wheelchair use had a TV power cord stretched tightly across the closet doorway, blocking access and creating an environmental hazard when staff had to lift the cord to open the closet. Another resident with severe cognitive impairment and a fall-risk care plan repeatedly ran barefoot in the hallway while staff observed but did not consistently provide planned interventions such as gripper socks, footwear, ambulation assistance, or redirection.
A resident with impaired cognition, cancer, non-Alzheimer's dementia, extensive ADL needs, and a fall history was identified as a high fall risk with care plan interventions including removing a movable bedside table. After a fall, the resident was found using the table as a walker, yet observations showed the table still placed beside the bed on multiple occasions, including when staff were present. Staff interviews confirmed they were unaware of the current fall prevention interventions and that the table remained at bedside for meals despite the care plan.
Failure to complete a restraint assessment before using a wheelchair alarm for a resident with muscle weakness, difficulty walking, repeated falls, and dementia. The care plan included the alarm as an intervention, but the record lacked an initial Restraint Evaluation, and the CNO confirmed the assessment had not been completed before the alarm was placed.
A resident with cognitive deficits, dementia, Alzheimer's disease, fracture, and repeated falls was dependent for toileting and care planned for an EZ stand with 2-person assist. During observed transfers, staff placed the harness and straps correctly, but the resident only rose to about 135 degrees and never came to a full stand, while staff remained by the bathroom door during privacy periods and continued the transfer despite the resident not standing fully. An RN stated the resident was expected to stand straight up with the EZ stand and that staff should sit the resident back down and try again if not.
A resident with Alzheimer's disease and dementia was found wandering in the parking lot after leaving the building unsupervised. A family member visiting another resident saw her looking into car windows and alerted staff, who were not aware she had exited until the report. Staff interviews showed the resident had been seen earlier eating in the dining room, but no one was actively looking for her or knew she had left the facility.
A resident with parkinsonism and Alzheimer's disease, severe cognitive impairment, and a fall history was pushed in her wheelchair without foot pedals and was not assisted when she called out for help. Nursing notes and staff interviews showed a CNA propelled the resident multiple times without foot pedals, including one instance where her socked foot hit the floor, and staff acknowledged that foot pedals should be used when pushing a resident.
Unsafe Cord Placement and Failure to Follow Fall Interventions
Penalty
Summary
The facility failed to ensure a television power cord was properly secured and maintained so it did not create an environmental accident hazard for R46. R46’s quarterly MDS identified moderate cognitive impairment, maximum assistance needed for dressing, grooming, and toileting hygiene, moderate assistance with transfers, and wheelchair use. During observation, R46 was in his room with the television mounted on the wall between the bathroom and closet, and the power cord ran across the closet doors and across the upper drawer of the dresser to a surge protector on top of the dresser. When R46 tried to open the closet doors, the cord was stretched tightly across the doorway and prevented the doors from opening fully unless the cord was lifted away. A later observation showed NA-D had to lift the cord above the closet door to open it and retrieve clothing. NA-D stated the cord had been positioned that way for about one year and could be dangerous if R46 pulled on it, and maintenance staff stated they were only notified that day that the television needed to be fixed. The facility also failed to ensure fall interventions were followed for R13, who had severe cognitive impairment with disorganized thinking and inattention, verbal behaviors toward others, and dependence on staff for footwear and partial to moderate assistance with dressing. R13’s care plan identified her as at risk for falls and included interventions such as ambulating with the resident, encouraging gripper socks, obtaining slip-on shoes, reducing noise, offering snacks, assisting her back to her room when running in the hallway, offering a wheelchair, and redirecting her to slow down. During observations, R13 repeatedly exited her room barefoot and ran through the hallway, including multiple times over an extended period, while staff observed but did not provide gripper socks or shoes, walk with her, redirect her to slow down, or offer other care-planned interventions. Staff interviews indicated they had difficulty redirecting her because she became agitated, and the DON stated the care plan should be followed to ensure safety.
Failure to Follow Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement care planned interventions to prevent further falls for one resident who was reviewed for falls. The resident had moderate impaired cognition, diagnoses including cancer and non-Alzheimer's dementia, required extensive assistance with ADLs including toileting, transfers, and locomotion, and had a history of falls. The resident's care plan identified the resident as a high fall risk related to de-conditioning, cognitive deficits, and prior falls, and included interventions such as anti-rollbacks on the wheelchair, appropriate footwear, keeping a wheelchair behind the resident when ambulating, and removing the mobile bedside table from beside the bed. After a fall in which the resident was found on the floor by the room doorway with the mobile bedside table in the hallway next to him, the resident stated he had been using the table as a walker. Despite the care plan and post-fall assessment identifying removal of the mobile bedside table as an intervention, observations showed the movable bedside table still placed alongside the bed on multiple occasions, including when staff were present in the room. Staff interviews confirmed they were unaware of the current fall prevention interventions, acknowledged the table was movable, and stated it remained at the bedside to facilitate meals. The DON confirmed the table had been at the bedside and was removed only after the surveyor discussed it with staff.
Failure to complete restraint assessment before wheelchair alarm use
Penalty
Summary
The facility failed to complete a restraint assessment before implementing a wheelchair alarm for Resident #18. Resident #18 was admitted with multiple diagnoses including muscle weakness, difficulty walking, repeated falls, and dementia. The care plan for impaired mobility and fall risk, dated 3/8/26, included a wheelchair alarm as an intervention. A Bed Safety and Transfer Device Evaluation dated 4/28/26 documented that the bed/chair alarm did not restrict mobility, but the record did not include an initial Restraint Evaluation dated on or around 3/8/26 to identify the comprehensive evaluation of the chair alarm. On 7/9/26, the CNO stated that a Restraint Evaluation had not been completed prior to the chair alarm being placed for Resident #18.
Inadequate Supervision During EZ Stand Transfers
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for one resident during transfers with an EZ stand lift. The resident had cognitive deficits and was dependent for toileting, with diagnoses including Alzheimer's disease, dementia, fracture, and repeated falls. The care plan identified a moderate fall risk related to weakness and directed toileting with an EZ stand and 2-person assist. During observation, nursing assistants placed the harness, safety belt, straps, and loops appropriately and assisted the resident with the lift, but the resident stood only to approximately 135 degrees and never came to a full stand. On two observed transfers, staff remained by the bathroom door while the resident was given privacy, then re-entered to continue the transfer and complete care. In both observations, the resident never achieved a full standing position despite encouragement and repeated attempts. One nursing assistant stated the transfer was safe because two staff were assisting, while the RN case manager stated she expected the resident to stand straight up when transferred with the EZ stand and that staff should sit the resident back down and try again if the resident did not. The RN case manager was unaware of any concerns about the resident transferring safely with the EZ stand. Facility policy was requested but not provided.
Resident Left Unsupervised and Was Found Wandering in Parking Lot
Penalty
Summary
The facility failed to recognize that a cognitively impaired resident had left the building unsupervised and was wandering in the parking lot. The resident had diagnoses including Alzheimer's disease, dementia, and anxiety disorder, and records showed she had moderately impaired cognition, walked and transferred independently, and had no documented wandering behaviors during the MDS lookback period. Although an elopement evaluation had previously concluded she was not at risk for elopement, the care plan identified confusion, impaired cognition, and lack of awareness of safety needs. On the day of the event, a family member visiting another resident saw the resident outside in the parking lot looking into car windows and walking from car to car with a jacket and pocketbook on her arm. The family member stated the resident appeared to be looking for someone and was in the middle area of the parking lot before she reported it to staff. Nurse #3 was notified and went to check on the resident, who was then brought back inside the facility. Staff interviews showed they were not actively looking for the resident and did not know she had exited the facility unsupervised until the family member reported seeing her outside. Staff accounts indicated the resident had been seen earlier in the dining room eating, but no one was aware she had left the building. Nurse #2 and NA #1 both stated they were not aware the resident was missing until the report from the family member. The administrator stated the resident exited through the front entrance doors, but it was not known whether she pushed the button behind the receptionist desk or was let out by a visitor. The previous NP stated the resident needed someone with her if she was outside the facility and could have wandered away if left alone.
Failure to Respond to Help Requests and Use Foot Pedals During Wheelchair Transport
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for R25 when staff did not respond to her requests for help and did not provide foot pedals while propelling her wheelchair. R25 had diagnoses of parkinsonism and Alzheimer's disease, and her records documented severely impaired cognition, including a BIMS score of four on a quarterly MDS. Her care plan stated she was independent with locomotion in her manual wheelchair, but other documentation reflected a history of falls and need for staff assistance with wheelchair mobility. The care plan also lacked documentation regarding foot pedals. Nursing notes and staff interviews showed multiple instances in which R25 was pushed in her wheelchair without foot pedals. On one occasion, a CNA propelled her out of the restroom and her socked foot hit the floor when the wheelchair was pushed. On another occasion, R25 was seated in her wheelchair, holding onto the back of a recliner and calling out for help, while the CNA walked by her. The CNA later propelled R25 down the hallway without foot pedals and at one point pushed the chair and let it go. Staff interviews confirmed that residents should have foot pedals when staff are pushing them, and the CNA stated she should not push R25 without foot pedals.
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