Failure to Update Care Plan and Ensure Safe Wheelchair Use Leads to Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to ensure an accident-free environment and provide adequate supervision to prevent accidents for a resident with significant mobility impairments. The resident, who had diagnoses including hemiplegia, hemiparesis following a stroke, paraplegia, and contractures, was assessed as having a high risk for falls and was totally dependent on staff for transfers and mobility. The care plan did not include updated or specific instructions from the rehabilitation department regarding the use of a recliner wheelchair and a non-slip mat (Dycem), which were necessary to safely position the resident and prevent falls. On the day of the incident, nursing staff placed the resident in a regular upright wheelchair instead of the recommended recliner wheelchair with a Dycem. The staff relied on verbal communication and did not have access to therapy notes or updated care plan interventions. The resident was left in a 90-degree upright position in the wheelchair, became agitated, and attempted to push himself forward, resulting in a fall and a minor head laceration. Interviews with staff revealed that the specific rehabilitation instructions were not documented in the care plan, and staff were unaware of the need for a recliner wheelchair and Dycem for this resident. The facility's policies required that care plans be updated as residents' conditions changed and that interventions be clearly documented to prevent accidents. However, the care plan for this resident lacked the necessary details about the type of wheelchair, positioning, and supervision required, leading to a breakdown in communication between the rehabilitation and nursing departments. This omission directly contributed to the resident being placed in an unsafe position, resulting in a fall and injury.