Failure to Ensure Wheelchair Leg Rests During Resident Transport Resulting in Fall
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for wheelchair mobility was transported without leg rests attached to the wheelchair. The resident, who had diagnoses including legal blindness, abnormal posture, and anxiety, was alert and oriented and required staff assistance for mobility. According to the resident's care plan, staff were directed to assist with transfers and ensure the use of a ROHO cushion in the wheelchair. During an incident, a housekeeper pushed the resident in the wheelchair without leg rests after an outdoor activity. While being transported, the resident's foot became caught in the wheelchair wheel, causing the resident to fall forward onto the pavement. The fall resulted in multiple injuries, including skin tears on the forehead, right hand, right elbow, both knees, a scrape on the bridge of the nose, and a laceration to the right forehead that required a suture. The housekeeper stated she was unaware that leg rests were required for the resident during transport and did not confirm this before moving the resident. The DON confirmed that all residents dependent on staff for wheelchair mobility require leg rests during transport and that staff are responsible for ensuring their use. No wheelchair transport policy was provided upon request.