Failure to Provide Ordered Wheelchair Safety Devices and Fall Interventions
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents at risk for falls were provided with ordered and care-planned safety devices, specifically wheelchair footrests, a wheelchair alarm, and a floor mat. Resident 1 was admitted with diagnoses including degeneration of the brain, dementia, weakness, and bilateral knee osteoarthritis, and had an MDS showing severely impaired cognition and a need for maximal assistance with most ADLs and locomotion on and off the unit. Resident 1’s orders included use of a wheelchair alarm when up in the wheelchair to alert staff if attempting to get up unassisted, and a floor mat on the right side of the bed to prevent injury from any fall. Despite these orders, observation and staff interview revealed that Resident 1’s wheelchair did not have footrests or a wheelchair alarm, and there was no floor mat in the room. Resident 2 was admitted with weakness, osteoporosis, and Alzheimer’s disease, and also had an MDS indicating severely impaired cognition and a need for maximal assistance with transfers, including sit-to-stand and chair/bed transfers, and supervision or partial assistance with other ADLs. The comprehensive care plan indicated a need for maximal assistance with locomotion on and off the unit. Physical therapy staff indicated that Resident 2 should have a footrest due to recent hospitalization, current weakness, and ongoing therapy three times a week. However, during observation in the activity room, Resident 2 was seated in a wheelchair without footrests. During the same observation in the activity room, both Resident 1 and Resident 2 were seen sitting in wheelchairs without footrests. The activity assistant present stated he had not been trained in transferring residents in wheelchairs and did not know why the residents did not have footrests. A CNA confirmed that Resident 1’s wheelchair lacked footrests and an alarm, and that there was no floor mat in the room, and began searching for the footrests. The QA nurse and MDS nurse both stated that residents with weakness, hemiplegia, or fall risk should have footrests, and that ordered alarms and floor mats should be implemented to ensure safety. The facility’s fall management policy stated that staff, in conjunction with the attending physician, will identify and implement appropriate interventions to reduce fall risk and minimize serious consequences of falling, but the ordered and recommended safety devices were not in place for these residents.
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