Failure to Ensure Safe Wheelchair Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, vascular dementia, depression, rheumatoid arthritis, and cancer was not properly protected from accident hazards during a wheelchair transfer. The resident required partial to moderate assistance for transfers and used a wheelchair for mobility. During an incident after a meal, a CNA assisted the resident by pulling the wheelchair away from the dining table and began pushing her forward without ensuring her feet were placed on the foot pedals. As a result, the resident's feet were under the foot pedals, and she fell out of the wheelchair, sustaining a contusion to the left forehead and an abrasion with bruising. The care plan for the resident indicated the use of a tilt-in-space wheelchair for mobility due to limited physical mobility and impaired self-care abilities. Despite this, the staff member failed to follow proper transfer procedures, as confirmed by video footage and staff interviews. The DON confirmed that the expectation was for staff to ensure residents' feet are on the foot pedals during transfers, which was not done in this case, directly leading to the resident's fall and injury.