Failure to Implement Wheelchair Safety Measures Results in Resident Harm
Penalty
Summary
A resident with a history of achondroplasia, muscle weakness, and repeated falls, who was dependent on staff for transfers and used a wheelchair, experienced two significant falls resulting in actual harm. The resident's care plan and Kardex specified the use of wheelchair leg rests and proper positioning as safety interventions. Despite these documented requirements, a nurse aide failed to apply the leg rests when transferring the resident to the wheelchair, citing that the leg rests caused the resident pain. The aide positioned the resident in front of the television without the required safety measures in place. The first incident involved the resident being found on the floor in front of the wheelchair with a hematoma on the forehead, necessitating hospital evaluation. The second incident occurred when the resident was again found on the floor in a pool of blood, having sustained a head injury that required sutures for a 3.5 cm laceration and treatment for a hematoma. In both cases, documentation indicated that the resident had been last seen by staff within a short period prior to the falls, and that the required safety interventions were not followed. Staff interviews and facility documentation confirmed that the nurse aide responsible had received education on the use of the Kardex and the necessity of using leg rests for this resident. However, the aide did not follow these instructions, resulting in the resident not being adequately supervised or positioned, which directly led to the falls and subsequent injuries. The facility acknowledged that the failure to implement the prescribed safety measures constituted neglect and resulted in actual harm to the resident.