Failure to Safely Transport Resident with Known Wheelchair Safety Risk
Penalty
Summary
A deficiency occurred when the facility failed to safely transport a resident with severe cognitive impairment and a history of putting her feet on the floor while being pushed in a wheelchair. The resident, an eighty-year-old female with severe dementia and agitation, was observed and reported by staff and her power of attorney to frequently place her feet on the ground during wheelchair transport. On one occasion, while being pushed toward the shower room, the resident placed her feet on the floor and fell forward out of the wheelchair, resulting in a laceration above her right eye that required three sutures and caused significant bruising. Multiple staff members, including CNAs and an LPN, confirmed that the resident had a longstanding behavior of putting her feet down during wheelchair movement, both when self-propelling and when being pushed by others. Despite this known behavior, the resident's care plan did not include any interventions or focus on this risk until after the incident. Additionally, the CNA who was pushing the resident at the time of the fall was not made aware of this behavior. The facility's fall prevention policy requires identification and documentation of resident risk factors for falls and the establishment of a resident-centered prevention plan, which was not followed in this case.