Failure to Ensure Wheelchair Safety Features Resulted in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident who used a manual wheelchair with anti-tippers had the anti-tippers removed during a dialysis treatment. The resident, who had a history of depression, obstructive uropathy, diabetes, and limited lower extremity mobility, was assessed as not cognitively impaired and had not experienced prior falls. Despite being care planned for fall risk and having anti-tippers as an intervention, the anti-tippers were removed at the dialysis center at the resident's request, and this change was not communicated to facility staff. Upon returning from dialysis, the resident attempted to board the facility van independently, positioning himself backwards on the van lift against the van driver's repeated instructions to wait for assistance and to face forward. Without the anti-tippers in place, the resident's wheelchair tipped backwards while the lift was flush with the ground, causing him to fall and sustain an abrasion to the back of his head and right elbow. The van driver did not notice the absence of the anti-tippers until after the incident, despite being responsible for ensuring the resident's wheelchair safety features were in place before transport. Multiple interviews confirmed that the anti-tippers were not on the wheelchair at the time of the fall, and that the resident had requested their removal while at the dialysis center. Facility staff, including the van driver and therapy staff, were aware that anti-tippers were a necessary intervention for this resident due to his high fall risk and double amputation. The lack of supervision and failure to ensure the resident's wheelchair was equipped with anti-tippers directly contributed to the fall and injury.