Failure to Prevent Accident Hazard During Wheelchair Transport
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) pushed a resident in a wheelchair without using leg rests, resulting in the resident's legs becoming trapped underneath the wheelchair. The resident, who had diagnoses of Parkinson's Disease and Alzheimer's Disease and was non-ambulatory, complained of pain after the incident. The CNA did not report the incident to nursing staff, despite the resident expressing discomfort. The resident was later found to have a swollen and bruised left leg, and subsequent medical evaluation revealed a complex comminuted fracture of the distal femur, requiring surgical intervention. The resident's care plan indicated a self-care performance deficit related to cognitive impairment and impaired balance, with interventions to encourage participation in activities of daily living and a note that the resident was non-ambulatory. The incident occurred when the CNA, who was aware that the resident typically self-propelled the wheelchair, chose not to use the leg rests while pushing the resident. The CNA acknowledged that the resident said "ouch" during the transfer but did not inform the nurse, as the resident stated they were okay. Other staff members were not made aware of the incident at the time, and the change in the resident's condition was only noticed later during routine care. Interviews with facility staff, including the assistant director of nursing (ADON), director of nursing (DON), and other CNAs and nurses, confirmed that the use of leg rests is expected when propelling residents in wheelchairs to prevent accidents. The facility did not have a specific policy on wheelchair safety beyond a general falls risk management policy. The lack of immediate reporting and assessment following the incident contributed to a delay in identifying the injury and providing appropriate care.