Failure to Lock Tub Chair Brakes During Transfer Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to properly utilize assistive devices necessary to prevent accidents for a resident with a history of frequent falls and an ADL deficit related to weakness. The facility's policies required staff to lock brakes on wheelchairs and tub chairs during transfers, and to ensure safe and proper use of assistive devices. However, during a transfer from a tub chair to a wheelchair in the shower room, the brakes on the tub chair were not locked. As a result, the tub chair rolled back while the resident was being assisted to stand, causing the resident to fall onto his right side. The incident was confirmed through resident and staff interviews, as well as a review of the medical record and facility policies. The event review documented that the CNA did not lock the tub chair brakes, directly leading to the fall.