Failure to Provide Wheelchair Footrests During Transport Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with a history of compression fracture, rheumatoid arthritis, spondylosis, and spinal stenosis, who required total staff assistance for transfers and supervision or touch assistance with wheelchair use, was transported to an outside medical appointment without wheelchair footrests. During the return from the appointment, the resident, who had just been fitted with a back brace and was sitting abnormally in the wheelchair, reported slipping out of the chair. The transport driver was unable to prevent the resident from falling forward out of the wheelchair, resulting in the resident hitting her head on the concrete sidewalk and sustaining a hematoma and scalp abrasion. The wheelchair used for transport did not have footrests, and the resident was unable to keep her feet elevated, which contributed to her slipping and falling from the chair. Interviews with facility staff confirmed that footrests are necessary for safe wheelchair transport unless specifically refused by the resident and care planned accordingly. The resident's care plan did not indicate any refusal or preference against footrest use. The facility's policy also required footrests to be used unless the resident self-propels. The lack of footrests during staff-assisted transport, combined with the resident's physical condition and recent back brace fitting, directly led to the fall and injury. There was no facility policy regarding footrest use at the time of the incident.