Failure to Use Appropriate Wheelchair Results in Resident Fall and Fractures
Penalty
Summary
A resident with cerebral palsy, weakness, anxiety, and diabetic neuropathy, who was cognitively intact but required substantial to maximal assistance for mobility and was dependent on nursing for all aspects of care, was not transported in the appropriate wheelchair. The resident's care plan specified the use of a standard wheelchair with footrests and proper body alignment. However, on the day of the incident, the resident was transferred by a CNA using a mechanical lift into a high back wheelchair that belonged to another resident. This high back wheelchair did not have footrests suitable for the resident, whose legs were too short to reach them, and the chair's design pushed on the back of the resident's head, forcing her forward. While being moved away from the dining room table by another CNA, the resident fell forward out of the high back wheelchair, hitting her face and left arm on the floor. The fall resulted in a left nasal bone deformity and fractures of both the ulnar and olecranon in the left upper extremity. Occupational therapy and nursing staff confirmed that the high back wheelchair was not appropriate for the resident due to her lack of core muscle control and inability to reposition or balance herself. The facility's own policy required assessment and management of falls through prevention and intervention, but the failure to use the correct wheelchair and ensure proper supervision directly led to the accident and resulting injuries.