Failure to Lock Shower Chair Brakes Leads to Resident Fall and Injury
Penalty
Summary
Facility staff failed to ensure the resident environment was free from accident hazards by not locking the shower chair brakes prior to transferring a resident, resulting in a fall. The resident, who had diagnoses including Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Osteoporosis, and a history of falls, was identified as a fall risk with impaired mobility and difficulty walking. The care plan included interventions for safe transfer techniques. During a transfer from a shower chair to a wheelchair, the certified nursing assistant (CNA) did not lock the shower chair brakes after moving the chair, which led to the chair moving unexpectedly when the resident attempted to stand and transfer. As a result of the unlocked shower chair, the resident fell, sustaining a fracture at the base of the left thumb, skin tears to both forearms, and a scalp hematoma. The resident was cognitively intact and able to describe the incident, confirming that the chair was not locked and moved out from under her during the transfer. The facility's policy on safe transfers required brakes to be locked prior to transfer, but this was not followed at the time of the incident. Staff interviews and documentation confirmed the failure to lock the brakes, which directly led to the resident's injuries.