Failure to Prevent Avoidable Fall Due to Missing Wheelchair Leg Rests
Penalty
Summary
A deficiency was identified when a resident with dementia, polyarthritis, muscle contracture, and severe cognitive impairment experienced a fall resulting in actual harm. The resident was dependent on staff for activities of daily living, including mobility and personal care. The care plan indicated the need for staff assistance and escort to activities. On the day of the incident, the resident was being pushed in a wheelchair by a GNA after breakfast, when the resident fell forward from the wheelchair, sustaining a laceration to the forehead and requiring hospital evaluation. The medical record and staff interviews confirmed that the wheelchair did not have leg rests attached at the time of transport, contrary to facility policy and staff expectations for safe resident transport. Further review revealed that the facility did not complete a summary of the investigation, witness statements, or a root cause analysis for the fall. Interviews with the Director of PT and the DON confirmed the requirement for leg rests when staff transport residents in wheelchairs, but neither could recall the specific incident. The GNA involved could not remember if leg rests were in place and reported that the resident's feet went under the wheelchair, causing the fall. The lack of proper wheelchair equipment and supervision directly contributed to the resident's avoidable fall and subsequent injury.