Failure to Implement Wheelchair Padding Results in Repeated Resident Injuries
Penalty
Summary
The facility failed to implement safety measures to prevent injuries for a resident with multiple medical conditions, including diabetes, respiratory failure, chronic kidney disease, heart failure, and dysphagia. Despite documented incidents of skin tears caused by the resident's legs coming into contact with the wheelchair leg rests during transfers, the intervention to pad the wheelchair leg rests was not put in place. The resident's care plan included padding the wheelchair leg piece and encouraging the use of long pants, but observations and interviews confirmed that the leg rests remained unpadded on both the old and new wheelchairs. Multiple staff members, including LPNs, CNAs, and the DON, verified that the intervention to pad the leg rests was not implemented, resulting in repeated skin tears for the resident. The resident and her daughter both reported ongoing injuries due to the lack of padding, and the daughter noted that even pool noodles brought from home to protect the bed frame were not used. Direct observation confirmed the absence of padding on the wheelchair leg rests, and the DON acknowledged that the failure to implement the intervention led to multiple injuries.