Failure to Ensure Safe Wheelchair Transport
Penalty
Summary
The facility failed to ensure safe wheelchair transport for a cognitively impaired resident, resulting in the resident sustaining significant bruising and pain. The resident, who has severe cognitive impairment and requires substantial assistance during wheelchair transport, was being transported by a CNA without the use of wheelchair leg rests. This oversight led to the resident's foot getting caught underneath the wheelchair, causing the resident to slide out and fall, hitting her head and sustaining a bruise on the right side of her face, forehead, and orbital area. Interviews with staff, including LPNs and CNAs, confirmed that the fall could have been prevented if leg rests were used during transport. The facility's incident report and nurse's progress notes corroborate the details of the fall incident. Despite the absence of a formal policy for safe wheelchair transport, the skilled therapy department's practice of using leg rests was not followed, contributing to the accident.