Failure to Implement Safety Measures for Wheelchair Transport and Fall Precautions
Penalty
Summary
The facility failed to implement adequate safety measures related to wheelchair transport and fall precautions for two residents. Resident R13, who had a history of stroke, Parkinson's Disease, and required assistance to propel a wheelchair, was involved in an incident where they were being pushed in a wheelchair without footrests attached. This led to the resident losing balance, falling, and sustaining an injury that required hospital admission. The facility did not have a policy for staff on the safe use of footrests during wheelchair transport, contributing to the incident. Resident R14, diagnosed with prostate and bone cancer and cognitive communication deficit, had a physician's order for a pressure alarm when in bed. However, during an incident, the pressure alarm was not plugged in, resulting in the resident falling, sustaining a head injury, and becoming unresponsive. The lack of a functioning alarm system meant that staff were not alerted in time to prevent the fall. These deficiencies highlight the facility's failure to ensure proper safety measures and supervision to prevent accidents.
Plan Of Correction
R13 and R14 have both returned to us from the hospital. Resident 13's wheelchair has wheelchair footrests. Resident 14 has orders for a bed alarm to check placement and function every shift. Current residents that utilized a wheelchair for mobility were verified that they have wheelchair footrests. Current residents that have bed or chair alarms orders were verified that they have current orders for check placement and function of alarms every shift. A wheelchair mobility procedure was developed for resident transportation. The Director of Nursing or designee will educate staff, including agency staff, on footrest usage with transporting residents in wheelchairs, as well as checking that all bed/chair alarms are plugged in and active prior to leaving a resident's room. Staff will be educated that residents will have orders for alarms, and staff will also check placement and function every shift, as well as verifying the alarm is active prior to leaving the resident unsupervised. Audits will be completed to ensure all residents being transferred in a wheelchair have footrests in use when assisting residents with mobility, as well as audits to ensure alarms in use are plugged in and active. These audits will be completed on 5 residents, 3 times a week for 2 weeks, and then monthly until cleared by Quality Assurance.