Resident Placed in Wheelchair Without Assessment Resulting in Fall
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's Disease and a history of falls was placed in a wheelchair without an assessment or care plan indicating the need or safety for wheelchair use. The resident was previously documented as ambulatory with a cane and identified as a fall risk with a history of wandering behavior. The fall care plan did not mention wheelchair use, and the physical therapy evaluation did not recommend or assess for wheelchair safety. Despite this, the resident was found sitting in a wheelchair and subsequently slid from it, landing on their buttocks. Record reviews and staff interviews confirmed there was no documentation of a wheelchair assessment or care plan for wheelchair use for this resident. Both the licensed nurse and the DON verified that the resident should not have been placed in a wheelchair, as there was no evaluation or recommendation supporting its use. The facility's fall management policy requires staff to identify interventions based on evaluations and current data, which was not followed in this case.