Failure to Prevent Accident Hazard During Wheelchair Transport
Penalty
Summary
A deficiency occurred when facility staff failed to ensure a resident's environment was free from accident hazards and did not provide adequate supervision or assistive devices to prevent accidents. Staff were aware that certified nursing assistants (CNAs) used a regular wheelchair to transport a resident with significant mobility limitations, including functional quadriplegia and a history of cervical spine fusion, over an elevated threshold to access the smoking area. The CNAs pulled the resident backwards in the wheelchair and tilted it to navigate the threshold, which resulted in the wheelchair tipping over and the resident falling backwards, striking his head and neck on the concrete floor. Nursing staff did not evaluate the hazardous nature of the travel path or the unsafe technique used to tilt the wheelchair. There was no consideration for a physical therapy evaluation for a new wheelchair with anti-tilt bars prior to the incident, despite the resident's complaints about the safety of the original wheelchair. Documentation following the fall was incomplete, with discrepancies in the location of the fall and lack of follow-up on radiology results. The resident experienced increased pain following the fall, and staff failed to ensure timely and complete assessment and documentation of the incident and its aftermath. Interviews and record reviews revealed that the path used for transporting the resident was not assessed for safety, and staff were not consistently informed or trained on safe transport practices. The facility's policies required identification and mitigation of accident hazards, but these were not followed in this case. The resident continued to use an unsafe path and wheelchair until after the incident, and staff did not adequately communicate or document the risks or interventions related to the resident's fall.