Failure to Use Wheelchair Footrests Resulting in Resident Fall During Transport
Penalty
Summary
The facility failed to ensure safe wheelchair transport and adequate supervision to prevent a fall for one resident. The resident had a resident assessment indicating she was severely cognitively impaired and a care plan identifying her as at risk for falls due to poor safety awareness and impulsiveness related to impaired cognition. Her care plan also noted glaucoma, prior falls with fractures, anxiety, unspecified psychotic disorder, and a cognitive communication deficit, all contributing to an increased fall risk. Despite these identified risks, the resident was transported in a wheelchair without proper use of the wheelchair footrests. A progress note documented that while a restorative CNA was pushing the resident in her wheelchair, the resident suddenly planted her feet on the ground as the wheelchair was moving, causing her to fall forward out of the wheelchair, landing on her knees and then rolling onto her back. She was sent to a local hospital and was found to have no injuries and returned the same day. Staff interviews later confirmed that the wheelchair foot pedals were not down and in place, and the CNA did not realize the resident’s feet were dragging on the floor under the wheelchair. The facility’s Safe Resident Lifting Policy required that all residents using a wheelchair have appropriate leg/footrests during transfers unless they self-propel, which was not followed in this incident.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.