Failure to Ensure Wheelchair Safety Equipment Resulted in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for wheelchair mobility was transported without the foot pedals attached to her wheelchair. The staff failed to ensure that the foot pedals, which are necessary for safe wheelchair transport, were in place. As a result, the resident was unable to rest her feet on the pedals while being moved from the dining room to her room. During this transport, the resident's foot or feet caught on a rug, causing her to fall forward out of the wheelchair and strike her head on the floor. The incident resulted in significant injuries to the resident, including a cervical (C1) spine fracture, a laceration and hematoma on her forehead, and a bruise on her left hand. The resident was assessed as being severely cognitively impaired, dependent on staff for all activities of daily living, and unable to walk. She was at high risk for falls, as documented in her care plan, and required staff assistance for all mobility. The care plan included interventions such as anti-tippers on the wheelchair but did not specify the consistent use of foot pedals during transport. Staff interviews revealed that it was common practice for some staff to transport residents without foot pedals if the resident had previously demonstrated the ability to lift their feet when requested. However, in this case, the resident was unable to keep her feet off the floor, leading to the accident. The investigation confirmed that the wheelchair did not have foot pedals attached at the time of the fall, and the staff member involved had been trained in wheelchair safety. The lack of foot pedals directly contributed to the resident's fall and subsequent injuries.