Failure to Assess Wheelchair Sizing and Follow Incident Reporting Policy
Penalty
Summary
A resident with multiple complex medical conditions, including morbid obesity, repeated falls, and non-ambulatory status, was not properly assessed for appropriate wheelchair sizing. The resident was transferred to a smaller, unstable wheelchair to accommodate transportation van limitations, despite the resident's usual need for a larger, more supportive wheelchair. The smaller wheelchair was reported to be broken and unable to safely support the resident, resulting in the resident falling and remaining on the floor of the van for an extended period. Multiple staff interviews confirmed that the wheelchair used was not suitable for the resident's size and needs, and that the resident expressed discomfort and dissatisfaction with the substitute wheelchair. The facility failed to follow its own Accident Incident/Fall Reporting Policy after the incident. There was no immediate assessment documented upon the resident's return, no incident report completed, and no evidence of a thorough investigation or root cause analysis as required by policy. The Director of Nursing acknowledged that risk management procedures were not followed, and that the incident was not properly documented or communicated to the necessary parties, including the resident's physician and family. Additionally, there was no documentation of a 72-hour post-incident assessment or neuro-checks as outlined in facility policy. Staff interviews revealed a lack of clear procedures for wheelchair assessment and documentation. The restorative nurse stated that while residents are measured for wheelchair suitability, there is no formal documentation of wheelchair size or reassessment following incidents. The absence of a documented process for ensuring proper wheelchair fit contributed to the use of an inappropriate wheelchair, which directly led to the resident's fall and subsequent complications during transport.