Failure to Prevent Wheelchair Fall Due to Inadequate Supervision and Lack of Safety Interventions
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and multiple medical diagnoses, including osteoporosis and a history of falls, was being transported in a wheelchair by a CNA. The resident, who typically self-propelled her wheelchair and did not use foot pedals, was being pushed by staff to the bathroom. During this transport, the resident dropped her feet, which became caught under the wheelchair, causing her to fall forward onto her knees and then onto her left side. This incident resulted in an acute comminuted fracture of the distal left clavicle. The resident's care plan documented a history of falls and included interventions such as therapy evaluation for wheelchair positioning and consideration of foot pedals. However, there was no evidence that these interventions were implemented prior to the incident. Staff interviews revealed that the resident had never used foot pedals on her wheelchair, as she used her feet to self-propel. The CNA pushing the wheelchair did not notice the resident's feet dropping, and the Therapy Director was not made aware of the need to evaluate for foot pedals until after the incident. Observations after the fall showed the resident continued to self-propel, with her left foot occasionally dragging and getting stuck on the floor. Documentation and interviews indicated a lack of communication and follow-through regarding the resident's need for wheelchair safety interventions. The Therapy Director stated she was not informed about the incident or the need for evaluation, and the DON and Administrator were unaware that therapy had not completed the assessment for foot pedals. The facility's fall prevention policy required individualized assessment and implementation of appropriate interventions, but these measures were not effectively carried out, resulting in the resident's fall and injury.