Failure to Prevent Wheelchair Fall Due to Missing Foot Pedals and Inadequate Supervision
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision and equipment use for a wheelchair-dependent resident, resulting in a right femur fracture. The resident had intact cognition with a BIMS score of 15 and was dependent on staff for most ADLs, including transfers, toileting, showers, and wheelchair mobility. The care plan documented that the resident had an ADL self-care deficit, required a Hoyer lift for transfers, had limited physical mobility related to morbid obesity, and could self-propel in a wheelchair, with foot pedals to be kept in a bag on the back of the wheelchair when not in use and staff to monitor safety on an ongoing basis. However, the care plan lacked specific mention of the right femur fracture, did not specify which limb was non-weight-bearing, and did not include clear interventions directing staff regarding the use of foot pedals for locomotion. On the date of the incident, camera footage showed a CNA propelling the resident in a wheelchair down a hallway slope without foot pedals attached, with the resident’s legs extended and not supported. As the wheelchair moved down the incline, the resident’s right foot dropped to the floor, became entangled under the wheelchair, and the resident fell to the floor, later confirmed by mobile X-ray and hospital records as a displaced right femoral neck fracture. The resident reported that the CNA pushed the wheelchair too fast and that no foot pedals were in place when her right foot went under the chair. Nursing notes contained conflicting descriptions of the event, including references to the resident self-propelling and the right ankle catching on a foot pedal, which were inconsistent with the video evidence of no foot pedals in use. Administrative staff acknowledged that the camera footage contradicted the nursing note about foot pedal use, that there was no MDS nurse to update care plans, and that no incident report, witness statements, or staff education were completed for this incident.
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