Failure to Use Wheelchair Foot Pedals Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when staff failed to follow appropriate safety measures while assisting a resident in a wheelchair, resulting in the resident falling and sustaining significant injuries. Specifically, a nurse was pushing the resident in his wheelchair to the front lobby for a dialysis appointment without attaching the foot pedals. As the wheelchair was pushed over a rug, the resident's feet fell to the floor, causing him to fall forward out of the wheelchair and sustain facial trauma, including a nasal and septal fracture, and a severe nosebleed. The resident required hospitalization, where he experienced complications such as recurrent bleeding, the need for nasal packing, limb restraints due to agitation, and a blood transfusion for anemia. The resident had a documented history of falls and was at risk due to weakness from chronic obstructive pulmonary disease and end stage renal disease requiring hemodialysis. The care plan in place prior to the incident included assistance with transfers but did not specify the use of foot pedals when staff propelled the wheelchair. Facility policy required foot pedals to be in place when residents could not self-propel, but this was not followed. Interviews with staff confirmed that foot pedals were not used during the incident, and that facility policy and best practices were not adhered to at the time of the fall.