Failure to Prevent Accident During Wheelchair Transport Results in Resident Injury
Penalty
Summary
A certified nursing assistant (CNA) failed to safely transport a resident in a wheelchair, resulting in the resident falling and sustaining a fractured hip. The CNA was pushing two residents simultaneously in their wheelchairs when one wheelchair caught on a window frame, causing the resident to fall forward onto her right hip. The resident, who had rheumatoid arthritis and contractures in her hands and knees, experienced significant pain and required emergency surgery for the hip fracture. The incident was witnessed by staff and captured on security video, confirming that the CNA was pushing two residents at once, which was not the proper procedure. Interviews with staff and residents revealed that there was inconsistency in staff understanding and adherence to safe wheelchair transport protocols. Several staff members, including CNAs and LPNs, reported that they had not received recent education or follow-up training regarding safe resident transportation or fall prevention policies. Some staff were unaware of the facility's policies or where to find them, and there was confusion among newer staff about whether transporting two residents at once was acceptable. The facility's investigation documentation did not include evidence of comprehensive staff education or clear communication of safety expectations following the incident. The resident involved in the fall had a care plan indicating dependence on staff for wheelchair locomotion and a need for reminders to use foot pedals, which she often refused due to her contractures. At the time of the incident, the resident was not using foot pedals, and the facility had noted a general lack of available wheelchair foot pedals. The facility's falls policy did not include provisions for staff education to prevent falls, and the investigation into the incident was limited, with only the CNA and the resident directly involved being interviewed. No disciplinary action or formal follow-up education was documented for the staff involved.