Failure to Ensure Wheelchair Safety During Resident Transport
Penalty
Summary
A deficiency occurred when a resident, who had diagnoses including paroxysmal atrial fibrillation, lymphedema, bilateral osteoarthritis of the knees, polyneuropathy, and osteoporosis, was pushed in a wheelchair without footrests by a staff member. The resident, who had no cognitive impairment, was returning to her room after an activity and was being assisted by an activity aide. The aide failed to attach the foot pedals to the wheelchair before pushing the resident, despite facility policy and care plan interventions requiring the use of leg rests during transportation for safety. The resident had her hands full of belongings and, as the wheelchair was being pushed quickly, she put her feet down and fell forward out of the chair, landing on her knees and hands. The incident was witnessed by staff, and the resident did not sustain injuries. Interviews with staff confirmed that the facility's expectation and policy were not followed, as foot pedals were not used during the transport. The care plan for the resident identified her as being at risk for falls due to impaired mobility and included interventions for staff education on the use of leg rests. The facility's safety policy also emphasized the importance of using leg rests for residents being transported in wheelchairs. The failure to follow these established protocols directly led to the resident's fall.