Failure to Ensure Safe Wheelchair Positioning and Supervision Results in Resident Fall and Injuries
Penalty
Summary
A deficiency occurred when staff failed to ensure a resident was properly positioned in a wheelchair while being transported, resulting in the resident falling and sustaining multiple serious injuries, including fractures. The resident, who had diagnoses of dementia, muscle weakness, and impaired mobility, required substantial assistance for transfers and was identified as at risk for falls due to lower extremity weakness and a history of falls. The care plan included interventions such as using a non-slip mat under the wheelchair cushion to prevent sliding. On the day of the incident, a nurse aide assisted the resident from the bathroom but did not ensure the resident was seated all the way back in the wheelchair. The aide then pushed the wheelchair at a fast pace despite the resident's verbal requests to stop, leading to the resident sliding forward and falling out of the wheelchair, hitting a dresser, and sustaining injuries. Witness accounts confirmed that the resident was not properly positioned and that the aide did not respond to the resident's requests to stop. The resident's roommate, who witnessed the event, reported that the aide attempted to move the resident after the fall without seeking immediate assistance from other staff. The facility's investigation into the incident was incomplete. The Director of Nursing did not document or fully investigate witness statements, did not clarify whether the resident was moved after the fall, and was unaware that staff had transferred the resident before EMS arrived. Additionally, there was a delay of nearly an hour before EMS was called, and the facility's policies regarding post-fall procedures and investigation documentation were not fully followed.