Failure to Safely Assist Resident During Weighing Results in Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident with a high risk for falls, significant medical history including a recent right hip replacement, spinal stenosis, osteoarthritis, and moderate cognitive impairment, was not safely assisted during a routine weighing procedure. The resident, who required substantial to maximum assistance with transfers and used a manual wheelchair, was being weighed on a platform scale with a sloped ramp. The Certified Nursing Assistant (CNA) assisting the resident backed the wheelchair onto the scale and, after weighing, pushed the wheelchair forward down the ramp, allowing the resident to face forward. As a result, the resident fell forward out of the wheelchair and sustained a vertebral fracture. The incident was witnessed, and it was documented that the resident hit his head and complained of pain on the right side. The resident was on blood thinners and had a history of falls, including a recent hip fracture at home that led to his admission for rehabilitation. The facility's own staff and the resident confirmed that the usual and safe practice was to push the wheelchair up the ramp facing forward and to pull the resident backwards down the ramp to prevent forward falls. However, on this occasion, the CNA did not follow this protocol, resulting in the resident's fall and injury. Interviews and record reviews revealed that the resident had experienced other falls in the facility, some due to self-transferring, but the fall during the weighing procedure was attributed to staff error. The facility's Director of Nursing and other staff acknowledged that the improper handling of the wheelchair on the scale ramp directly led to the resident's fall and subsequent lumbar fracture. The facility's fall prevention policy emphasized the need for an environment free from hazards and appropriate supervision, which was not adhered to during this incident.