Failure to Ensure Safe Transfer and Supervision During Wheelchair Use
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide adequate supervision and safe transfer for a resident with paraplegia and multiple other diagnoses, including lack of coordination and neuromuscular dysfunction of the bladder. The resident, who used a motorized wheelchair and was care planned to require staff assistance for safe transfers, was being assisted by the CNA from bed to wheelchair. During the transfer, the CNA operated the motorized wheelchair by pressing the joystick, causing the wheelchair to move rapidly into a wall and strike the resident's foot. The resident reported pain in her foot immediately after the incident, though the pain had resolved by the time of the interview. The CNA admitted to not reporting the incident to a nurse at the time, stating she was distracted by other tasks and forgot to do so. The CNA also acknowledged she had not properly operated the wheelchair and was later inserviced on the correct procedure, which involved unlocking and manually pushing the wheelchair rather than using the joystick during transfers. The Director of Nursing (DON) and Administrator only became aware of the incident the following day when the resident reported it. The DON assessed the resident and ordered x-rays, which were negative for injury. The facility did not have a policy on accident hazards available when requested by the surveyor. The lack of immediate reporting and improper handling of the motorized wheelchair during transfer led to the deficiency in providing a safe environment and adequate supervision.