Resident Fall Due to Lack of Wheelchair Footrests During Transport
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral palsy, functional quadriplegia, contractures, and balance deficits was being transported in a wheelchair by a CNA without the use of footrests. The resident, who was able to self-propel using one foot, was being pushed by staff when her foot caught on the ground, causing her to fall forward out of the wheelchair. As a result, the resident sustained abrasions to her face and wrist, a skin tear, and a laceration to her lip. She also experienced pain in her back, mouth, face, and chest, and exhibited shallow breathing following the incident. Medical records indicated that the resident was unable to brace herself during the fall due to her physical limitations. The incident required emergency medical services, and the resident was transferred to a hospital for evaluation. Subsequent assessments confirmed no fractures, but superficial injuries were present. The deficiency was identified through observation, interviews, and record review, which confirmed that the resident did not have appropriate supervision and safety measures in place to prevent the accident during wheelchair transport.