Failure to Assess and Supervise Wheelchair Use Resulting in Resident Injury
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for a resident who self-propelled in a wheelchair. Nursing staff were aware that the resident used a wheelchair equipped with foot pedals and self-propelled throughout the facility, but did not assess the safety or appropriateness of the wheelchair for the resident's physical size, abilities, or declining mobility. The resident was not evaluated or fitted for a personal wheelchair and instead used wheelchairs available for general use in the facility. Staff did not identify or address the resident's declining upper and lower extremity mobility as documented in the Minimum Data Set (MDS), nor did they refer the resident for a physical therapy assessment or update the care plan to address wheelchair use and safety. As a result of these failures, the resident experienced an unwitnessed, avoidable accident in which their legs became entangled in the wheelchair while self-propelling, leading to severe pain and a right lower leg injury. The resident was subsequently diagnosed with acute right tibial and proximal fibular fractures, requiring hospitalization and resulting in loss of mobility and increased isolation. Interviews with nursing staff and CNAs revealed that none were aware of a safety assessment for the resident's wheelchair use, and there was no documentation of a physical therapy referral, physician notification regarding the resident's functional decline, or a care plan component addressing wheelchair safety. Facility policy required that recommendations for assistive device use be based on comprehensive assessment and documented in the care plan, including evaluation of appropriateness for the resident's condition and personal fit. However, these policies were not followed, as confirmed by staff interviews and record reviews. The lack of assessment, supervision, and individualized equipment fitting directly contributed to the resident's accident and subsequent injury.