Failure to Ensure Safe Wheelchair Transport Results in Resident Injury
Penalty
Summary
A certified nursing assistant (CNA) failed to follow facility guidelines for wheelchair use when assisting a resident who was self-propelling in her wheelchair. The CNA pushed the resident's wheelchair without ensuring the foot pedals were in use, despite the facility's practice of following American Healthcare Association guidelines for wheelchair safety. The foot pedals had been rotated to the sides of the wheelchair and were not being used at the time of the incident. As the CNA pushed the resident around a hallway corner, the resident's right foot became lodged under the wheelchair, resulting in the right front wheel rolling over her foot. The resident called out for the CNA to stop due to pain. The incident was not immediately reported to nursing staff by either the CNA or the resident. The resident later experienced pain and an inability to bear weight on her right leg during a therapy session, which led to notification of the nurse and subsequent medical evaluation. The resident, who was cognitively intact and had a history of chronic kidney disease, peripheral vascular disease, morbid obesity, and frequent falls, was transferred to the emergency department for assessment. Imaging revealed degenerative changes in the knee but no fractures. The resident was provided with a knee immobilizer for comfort. The facility did not have a specific policy on wheelchair use but indicated adherence to external guidelines, and the incident highlighted a failure to ensure safe wheelchair transport and adequate supervision to prevent accidents.