Failure to Ensure Safe Wheelchair Transport for High Fall Risk Resident
Penalty
Summary
A deficiency occurred when staff failed to ensure safe wheelchair transport for a resident identified as high fall risk. The resident, who had multiple diagnoses including dementia, neuromuscular dysfunction, muscle wasting, abnormalities of gait and mobility, and was cognitively intact, was transported in a wheelchair without footrests in place. During transport, the resident's shoes made contact with the floor multiple times, and it was observed that footrests were not used despite the resident not refusing them. The resident reported that footrests had not been used for some time and acknowledged that they help prevent his feet from hitting the floor. The incident leading to the deficiency involved a CNA propelling the resident in his wheelchair when the resident fell forward, resulting in a broken nose and a laceration to the forehead that required sutures. Staff interviews revealed that it was common practice to transport the resident without footrests, relying on the resident to lift his feet. There was no documentation indicating that the resident refused the use of footrests, and staff were unable to confirm if the available footrests belonged to the resident's wheelchair. The facility's Director of Nursing and therapy staff confirmed that footrests are an important safety measure during wheelchair transport to prevent accidents. The facility did not provide a specific wheelchair transport policy when requested. The only available policy referenced safe lifting and movement of residents but did not address the use of footrests during wheelchair transport. The lack of adherence to safe transport procedures and absence of documentation regarding the use or refusal of footrests directly contributed to the resident's fall and subsequent injuries.