Failure to Ensure Motorized Wheelchair Safety During Care Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident who ambulated via a motorized wheelchair sustained minimally displaced fractures of the 2nd through 4th metatarsal necks after a certified nursing assistant (CNA) failed to turn off the wheelchair while providing care. The incident took place in the shower room, where the CNA, while leaning over the resident, accidentally bumped the wheelchair's joystick, causing the wheelchair to move forward and the resident's feet to strike the wall. The resident, who had a history of multiple sclerosis, bilateral hemiplegia, muscle contractures, and was dependent on staff for all activities of daily living, was cognitively intact and had been using the motorized wheelchair for five years. The care plan for the resident included interventions for safe wheelchair operation and staff assistance with mobility and personal care. However, the care plan did not specify that staff must turn off the motorized wheelchair during care, and the CNA involved reported not having received training on this safety measure prior to the incident. The resident stated that staff were supposed to turn off the wheelchair during care, but was unsure if this was consistently done before the incident. The CNA confirmed that she previously left the wheelchair on during care and only began turning it off after the incident occurred. Documentation and interviews confirmed that the incident resulted in the resident experiencing pain and requiring medical intervention, including immobilization of the affected foot. The facility's policy defined accidents and incidents but did not provide specific guidance on the safe handling of motorized wheelchairs during care. The failure to ensure the wheelchair was turned off during care directly led to the resident's injury.