Failure to Prevent Resident Fall Due to Neglect of Wheelchair Safety Precautions
Penalty
Summary
A deficiency occurred when facility staff failed to protect a resident with vascular dementia and significant cognitive and physical impairments from neglect, resulting in a serious fall from a wheelchair. The resident was assessed as high risk for falls, with documented poor recall, judgment, and safety awareness, and was dependent on staff for all mobility and transfers. Physical therapy and nursing assessments consistently indicated the resident required two-person assistance and the use of leg rests and other safety precautions when being transported in a wheelchair. On the day of the incident, a nurse aide was observed pushing the resident in a wheelchair at a high speed and without leg rests. Multiple staff statements confirmed that the resident was being transported in this unsafe manner, despite prior education and warnings given to the aide the previous day regarding the necessity of using leg rests and not pushing residents quickly. During transport, the resident fell forward out of the wheelchair, sustaining a laceration to the forehead and a serious brain injury, including intraparenchymal and subarachnoid hemorrhages, as confirmed by hospital documentation. The facility's documentation and staff interviews revealed that concerns about the aide's unsafe transport practices had been identified the day before the incident, and the aide had been instructed on proper procedures. However, these interventions were not effectively implemented, and the resident was subsequently injured due to the same unsafe practices. The failure to ensure staff followed required safety interventions directly led to the resident's fall and serious injury.