Failure to Remove Wheelchair Foot Pedals and Provide Supervision Resulting in Resident Fall
Penalty
Summary
The facility failed to properly utilize assistive devices necessary to prevent accidents for a resident who sustained a fall. According to the facility's Standards of Care, wheelchair foot pedals are to be used during transport for extended distances and removed when the resident is stationary, unless otherwise care planned. The resident, who had recently returned from hospitalization for pneumonia, was brought to the dining room in a wheelchair by a CNA. The CNA left the resident at the table with the wheelchair pedals still attached and then left the area to dispose of garbage, stopping to speak with an RN along the way. Although the CNA had asked the RN about the foot pedals and was told they should be removed, the CNA did not return to remove them before leaving the resident unattended. While the CNA was away, the resident attempted to stand and subsequently fell, striking the back of his head on a dining room chair. The care plan for the resident indicated a need for assistance with ambulation using a gait belt and hand-held assist, but this was not followed at the time of the incident. The failure to remove the wheelchair foot pedals and provide adequate supervision contributed to the resident's fall.