Failure to Provide Wheelchair Leg Rests and Supervision Leads to Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to ensure that a resident with multiple sclerosis, dementia, and moderate cognitive impairment remained as free from accidents as possible. The resident, who was dependent on staff for activities of daily living and used a wheelchair, had a care plan indicating the need for extensive assistance and the use of bilateral footrests as needed. Despite this, the resident was being transported by a Licensed Nursing Assistant (LNA) without the required leg rests in place. During transport, the resident's foot became caught under the wheelchair, resulting in a fall that caused abrasions and swelling to the left knee and right hand. Interviews and record reviews confirmed that the facility's practice was to use leg rests for residents who do not self-propel, but there was no evidence that staff had been educated on this requirement. The Director of Nursing (DON) acknowledged that the resident required assistance and did not self-propel, and could not provide documentation of staff education regarding the use of wheelchair leg rests. The failure to implement and educate staff on appropriate interventions and assistive devices directly contributed to the resident's fall and subsequent injuries.