Failure to Ensure Wheelchair Safety and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure resident safety by not placing foot pedals on a resident's wheelchair while the resident was being propelled by staff. This omission resulted in the resident placing her feet on the floor and falling forward out of the wheelchair, causing significant facial lacerations that required eleven sutures. The incident occurred despite the resident having a documented history of high fall risk, severe cognitive impairment, and dependence on staff for mobility and personal care. Staff interviews confirmed that there was no facility-wide policy or process to assess the need for foot pedals when residents were being propelled, and a similar incident had occurred with another resident in the past without subsequent changes to practice. Additionally, the facility failed to implement fall prevention interventions as outlined in the resident's care plan. The care plan specified that the resident's bed should be in the lowest position and a safety mat should be placed on the left side of the bed. However, observations revealed that the bed was not in the lowest position and the safety mat was not in place, contrary to both the care plan and physician orders. Staff and administrative interviews confirmed that these interventions were still current and required for the resident. Multiple staff members, including nursing, housekeeping, and family members, were observed propelling residents in wheelchairs without foot pedals, with residents holding their feet up off the floor. The lack of a standardized assessment or policy regarding the use of foot pedals contributed to the unsafe environment and directly led to the resident's fall and injury. The facility's inaction following a previous similar incident further demonstrates the ongoing failure to address this safety hazard.