Failure to Timely Report Resident Incident Involving Motorized Wheelchair
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to immediately report an incident involving a resident and a motorized wheelchair. The resident, who had paraplegia, personality disorder, anxiety, PTSD, paralytic syndrome, tobacco use, neuromuscular dysfunction of the bladder, and lack of coordination, was being assisted by the CNA for a transfer from bed to wheelchair. During the transfer, the CNA pressed the joystick on the motorized wheelchair, causing it to move quickly into a wall and strike the resident's foot. The resident reported experiencing pain at the time of the incident. Despite the incident, the CNA did not notify the nurse, Director of Nursing (DON), or administrator immediately as required by facility policy. The CNA stated she intended to report the incident but forgot due to being occupied with multiple tasks. The resident later reported the incident and her foot pain to the DON the following day, prompting an assessment and further action. The delay in reporting meant that the incident was not addressed promptly, and the required notifications to facility leadership and authorities were not made within the mandated timeframe. Interviews confirmed that the DON and administrator were unaware of the incident until the resident self-reported the next day. Facility policy requires all known or suspected incidents of abuse, neglect, or accidents to be reported immediately to the administrator or designee. The failure to report the incident in a timely manner constituted a breach of this policy and regulatory requirements.