Failure to Maintain Safe Wheelchair Condition Leads to Resident Fall
Penalty
Summary
The facility failed to ensure that a wheelchair was maintained in safe operating condition for one resident. According to nursing notes, the resident experienced a witnessed fall after being lowered to the floor from a lift, with a CNA reporting that the resident had unclamped the sling and was then lowered without head injury. Later, a CNA stated that when the resident was transferred into his reclining chair, the wheelchair was broken and tilted forward, causing the resident to slide out. Multiple CNAs confirmed that the wheelchair had been broken and in a forward-tilted position for some time prior to the incident, and that it was eventually switched out due to discomfort and safety concerns. The Maintenance Director reported that repairs are tracked through a logbook, but there was no record of the broken wheelchair, and he was never notified of the issue. Facility policy requires maintenance work orders to be filled out and forwarded to the Maintenance Director, with emergency requests prioritized, but this process was not followed in this case.