Failure to Use Wheelchair Foot Pedals Results in Resident Fall and Injury
Penalty
Summary
The facility failed to ensure that wheelchair foot pedals were in place prior to propelling a resident in a wheelchair, resulting in a fall and serious injury. A resident with multiple diagnoses, including hemiplegia, muscle weakness, unsteadiness, and a history of falls, was being transported by an activity aide without foot pedals attached to the wheelchair. The resident, who was dependent on staff for wheelchair mobility and did not self-propel, placed her feet on the floor while being moved and subsequently fell forward from the wheelchair, striking her head on the tile floor. This incident led to a subarachnoid hemorrhage and required an overnight hospital stay. Interviews and record reviews confirmed that staff routinely propelled the resident without foot pedals, despite the resident's care plan identifying her as at risk for falls and requiring substantial assistance for mobility. Occupational therapy staff noted that while the resident had foot pedals available, they were not often used, and the resident was known to refuse them on occasion. Multiple CNAs confirmed the absence of foot pedals prior to the fall and acknowledged the risk of falling due to their non-use. The facility's fall prevention program required individualized interventions and the use of assistive devices for residents at risk, but these measures were not implemented for this resident at the time of the incident.