Failure to Investigate and Prevent Resident Injury Involving Wheelchair Leg Rest
Penalty
Summary
A deficiency was identified when the facility failed to thoroughly investigate an incident involving two residents with severe cognitive impairment who shared a room. On the evening of the incident, a Licensed Practical Nurse responded to a loud noise and found one resident sitting on the floor with a laceration and swelling to the left side of the face, while the other resident was standing nearby holding a wheelchair leg rest. The injured resident was assessed and subsequently transferred to the hospital, where soft tissue swelling and a hematoma were confirmed. The second resident was also evaluated at the hospital and found to have no physical injuries. The facility's investigation did not determine how the resident obtained the wheelchair leg rest or where it originated from. Interviews with staff, including the Director of Nursing and Registered Nurse Supervisors, revealed uncertainty about the source of the leg rest and the storage practices for wheelchair components. Staff reported that wheelchair leg rests were sometimes left attached to wheelchairs, placed on seats, or stored in various locations such as storage rooms, hallways, or resident rooms. Despite these findings, the investigation did not address the accessibility of the leg rest or implement any interventions to prevent recurrence. The facility's policy required immediate and thorough investigation of all alleged abuse, including examination of the environment for items involved in the incident. However, documentation showed that the investigation did not include a review of how the leg rest became accessible to the resident or any preventive measures. The Director of Nursing acknowledged that no interventions were put in place following the incident, and this was the first such occurrence involving a wheelchair leg rest at the facility.