Failure to Ensure Wheelchair Foot Pedals Resulted in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when staff failed to ensure that foot pedals were attached to a resident's wheelchair while the resident was being pushed by a licensed nurse. The resident, who had a history of Lewy body dementia, congestive heart failure, chronic pain syndrome, and repeated falls, was known to have severely impaired cognition, poor safety awareness, and a high risk for falls. The care plan identified the resident as a high fall risk and included several interventions for supervision and fall prevention, but did not specify the use of foot pedals on the wheelchair. On the day of the incident, the resident was being assisted by a licensed nurse who propelled the resident in a wheelchair without foot pedals. The resident placed her feet on the ground while being pushed, which caused her to fall headfirst to the floor. As a result, the resident sustained a 7.5 cm laceration on her forehead, a small hematoma, and required emergency transfer for evaluation and suturing of the wound. Observations and interviews confirmed that the wheelchair did not have foot pedals at the time of the fall, and that this was not an isolated issue, as other wheelchairs in the facility were also observed without foot pedals. The facility's fall risk assessment policy required identification and mitigation of environmental hazards and the addition of interventions to care plans to minimize fall risks. However, the lack of foot pedals on the wheelchair during transport directly contributed to the resident's fall and injury. Staff interviews revealed that there was no prior education or specific intervention in the care plan regarding the use of foot pedals, and audits after the incident found that other residents' wheelchairs also lacked foot pedals.