Failure to Train Nursing Staff on Tilt-in-Space Wheelchair Use
Penalty
Summary
Nursing staff failed to receive proper training on the use of a Tilt-in-space wheelchair prior to its use for a resident with cognitive communication deficits, Alzheimer's disease, and legal blindness. The resident, who required maximum assistance for activities of daily living, was transferred from a mechanical lift into the Tilt-in-space wheelchair by a CNA and an LVN. After the transfer, the resident was positioned upright in the chair and began to slide down towards the floor, as documented in a witnessed fall report. Interviews with the CNA and LVN involved in the transfer revealed that neither had been trained on the use of the Tilt-in-space wheelchair before the incident. The Director of Rehabilitation confirmed that she had not provided training to the CNA prior to the event and stated that all staff should be trained on such equipment before use. The facility's policy required staff unfamiliar with a wheelchair model to receive instruction or guidance before use, but this was not followed in this case.