Failure to Prevent Fall Due to Improper Wheelchair Transfer
Penalty
Summary
A deficiency occurred when staff failed to prevent a fall for a resident with significant physical impairments, including muscle wasting, atrophy, anoxic brain damage, and no trunk control. The resident was dependent on two staff members and a mechanical Hoyer lift for transfers and required the armrests of his motorized wheelchair to be down for safety. On the day of the incident, after being transferred to his wheelchair, the left armrest was left up, and the staff member left the room. As a result, the resident fell sideways out of the chair and sustained a head injury, requiring hospital transfer. The incident report confirmed that the fall was due to the armrest being left up during the transfer. Interviews with staff revealed that the CNA assisting with the transfer was not adequately trained on the specific requirements for transferring this resident into the motorized wheelchair, particularly regarding the necessity of ensuring the armrests were down. The CNA also indicated that she was assigned to a different hall and had to leave the room due to other duties, which contributed to the lack of supervision. The Director of Nursing confirmed that the fall occurred because the armrest was not down and the resident lacked core strength, leading to the accident.