Failure to Maintain Wheelchair in Safe Repair Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's wheelchair was maintained in safe repair, resulting in an accident. The resident sustained a 7 cm L-shaped laceration on her right lower leg after her skin caught on the uncapped right front wheel connector of her wheelchair while transferring from the wheelchair to the toilet. The injury was severe enough to require the resident to be sent to the hospital, where she received 11 sutures. Observations on subsequent days confirmed that the right front wheel connector of the wheelchair remained uncapped. Interviews with facility staff revealed that the LPN who responded to the incident did not notice the uncapped connector at the time, but the Rehab Director and Nurse Practitioner later confirmed that the connector should have been capped and that its condition likely contributed to the injury. The Director of Nursing stated that staff are expected to report any medical equipment in disrepair, including wheelchairs, and that all equipment should be kept in good, safe repair to prevent injuries. The facility's maintenance policy requires the maintenance of equipment and the building environment.