Failure to Ensure Use of Wheelchair Foot Pedals Resulting in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with a history of repeated falls, traumatic subdural hemorrhage, and moderate cognitive impairment fell from her wheelchair and sustained a laceration to her forehead that required sutures. The incident took place when the resident was being transported in her wheelchair without the required foot pedals in place, contrary to facility policy. The absence of the foot pedals caused the resident to fall forward out of the wheelchair, resulting in injury. Record review showed that the resident had a care plan identifying her as being at risk for falls, with multiple falls reported in the previous six months, including one that led to her current admission. On the day of the incident, staff responded to a call for help and found the resident on the floor, bleeding from her forehead. The injury could not be controlled with pressure, and the resident was transported to the emergency department, where she received sutures before returning to the facility. Interviews with staff revealed that the use of wheelchair foot pedals was expected and outlined in facility policy, which required pedals to be used unless otherwise care planned. However, at the time of the incident, the pedals were not attached to the resident's wheelchair. Staff acknowledged awareness of the importance of using foot pedals, and the director of nursing confirmed that no formal monitoring mechanism was in place to ensure compliance with this requirement.