Failure to Assess and Address Wheelchair Safety After Resident Injuries
Penalty
Summary
The facility failed to evaluate and address hazards and risks for a resident who was cognitively intact but had significant physical limitations, including diabetes mellitus, morbid obesity, muscle weakness, and gout. The resident required the use of an electric wheelchair for mobility. Despite these risk factors, the facility did not complete a wheelchair skill or safety assessment after the resident sustained a right leg fracture in June, which occurred when the resident's leg became caught in a courtyard doorway while using the wheelchair. Medical documentation confirmed the injury, including an orthopedic note and X-ray results showing an acute, nondisplaced oblique fracture of the distal tibial diaphysis. Additionally, the resident experienced a large bruise to the left calf after bumping into a bed with the wheelchair in October. Interviews with both the resident and the Physical and Occupational Therapy Director confirmed that no wheelchair safety assessments were conducted following either incident. The care plan only included an intervention to educate the resident on proper use of mobility devices, with no further interventions or assessments added after the injuries. An RN confirmed that safety assessments should have been completed for all residents using power wheelchairs.