Resident Injury Due to Improper Wheelchair Transport
Penalty
Summary
A resident with multiple diagnoses, including osteoporosis, left hemiparesis, Parkinson's disease, and a history of stroke, was identified as high risk for falls. The resident was being transported in a wheelchair without foot pedals in place. During this transport, the resident's weak leg became caught in the front wheel of the wheelchair, causing the resident to fall forward onto her face and sustain a bilateral nasal bone fracture and soft tissue hematoma. The resident reported significant pain, anxiety, and visible injuries following the incident. Staff interviews confirmed that the footrests were not attached to the wheelchair at the time of the fall, and that the resident's foot became entangled in the wheel, leading to the accident. The acting DON stated that it was her expectation that foot pedals should be in place when transporting residents in wheelchairs. The facility did not provide a policy regarding the use of foot pedals during transport. This failure to ensure proper use of wheelchair footrests resulted in the resident's injury.