Failure to Use Wheelchair Leg Rests During Staff-Assisted Propulsion Resulting in Resident Fall and Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and assistance devices to prevent accidents, specifically related to wheelchair safety and use of leg rests. Facility policies required that the resident environment remain as free of accident hazards as possible and that residents using wheelchairs be provided with properly positioned foot pedals/footrests prior to staff-assisted wheelchair propulsion, unless clinically contraindicated and documented in the care plan. These policies emphasized that wheelchair mobility could be self-propelled by the resident or assisted by staff, based on the resident’s needs, and that footrests must be in place when staff are propelling the wheelchair. The resident involved had diagnoses including a history of falling, muscle weakness, acute and chronic respiratory failure, and COPD. He typically self-propelled his wheelchair throughout the facility using his feet and did not have leg rests on his wheelchair for that purpose. On the day of the incident, progress notes documented that he was found lying on the floor in the hallway outside the dining room on his left side, with an abrasion to his forehead and a swollen, deviated nose. He was alert, answered questions appropriately, denied pain, and had normal neurological checks and extremity movement. Subsequent x‑ray reports showed an acute, depressed fracture of the distal third aspect of the bridge of his nose. Witness statements from staff described that the resident’s feet became tangled or caught while he was in his wheelchair near the dining room doorway, leading to his fall. One nurse aide stated that the resident was rolling out of the dining room when his feet got tangled and he fell. Another nurse aide reported that the resident was sitting in front of the dining room doorway and that when a staff member pushed his wheelchair to move him so other residents could get through, his foot got caught in the wheel and he fell forward out of the chair; this statement also noted that the resident did not wear leg rests because he self‑propelled during the day. A licensed practical nurse reported observing a nurse aide pushing the resident in his wheelchair when the resident’s foot became caught, causing him to fall forward out of the wheelchair onto the floor, while another aide nearby appeared to be attempting to alert the aide who was pushing the chair. The nursing home administrator later confirmed that the resident typically self‑propelled without leg rests and that the aide should have applied leg rests if she was going to move or transport the resident in his wheelchair.
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.