Failure to Prevent Accident Hazard During Therapy Session
Penalty
Summary
A deficiency occurred when a Certified Occupational Therapy Assistant (COTA) used a rollator, a four-wheeled walker with a seat, during a therapy session with a resident who had previously been assessed as unsafe to use this device. The resident, who had diagnoses including diabetes, chronic obstructive pulmonary disease, and generalized muscle weakness, had been evaluated by physical and occupational therapy, both of which determined that her safest mobility aids were a front wheel walker and a wheelchair. Despite this, the COTA allowed the resident to demonstrate how she intended to use a rollator at home, even though the resident had been educated multiple times about the safety risks associated with the rollator and had previously lost balance while using it during therapy sessions. During the therapy session, the resident stood up from the locked rollator, unlocked the brakes, and while turning to walk forward, fell against the counter and slid to the floor. The COTA had not consulted with the occupational therapist or other supervisors before allowing the resident to use the rollator, and the session was not part of the established treatment plan. The COTA stated that her intention was to show the resident the risks of using the rollator, but she did not anticipate the resident would use it as a wheelchair or that a fall would occur. The occupational therapist and Director of Rehabilitation both confirmed that the rollator was not safe for the resident and that its use was not authorized in the care plan. As a result of the fall, the resident sustained a nondisplaced left greater trochanter fracture and was sent to the emergency department for evaluation and pain management. The incident was witnessed by therapy staff, and subsequent interviews with facility staff, including the Medical Director, Director of Nursing, and Administrator, confirmed that the use of the rollator was not appropriate for the resident and that proper supervision and adherence to the care plan were not maintained during the therapy session.