Failure to Use Wheelchair Leg Rests During Transport Resulting in Resident Fall and Injury
Penalty
Summary
The facility failed to ensure a resident was provided with necessary wheelchair equipment, specifically leg rests, to ensure safety and proper positioning during transport. Facility policy on assistive devices and equipment stated that devices such as wheelchairs are to be provided based on comprehensive assessment and documented in the care plan, and that staff are to be trained and competent in their use. The resident involved had dementia, difficulty walking, muscle weakness, a history of falls, and used a wheelchair for locomotion. A quarterly MDS showed the resident required assistance with mobility and had moderate cognitive impairment. The resident’s care plan identified high fall risk related to confusion and psychoactive drug use, with interventions including supervised out-of-bed time and physical therapy for mobility and trunk control. On the date of the incident, nursing notes documented that the resident was taken to their room by a nurse and fell forward to the floor, resulting in a large hematoma on the left forehead and subsequent transfer to the hospital, where a left frontal scalp hematoma and periorbital contusion were diagnosed. Facility documentation from that date did not include resident or staff statements describing the incident or contributing factors. In later interviews, the OT and Director of Rehabilitation confirmed that facility practice requires wheelchair leg rests to be applied during transport by nursing staff, regardless of whether residents can self-propel. An LPN and a nurse aide both reported that while the aide was transporting the sleepy resident to their room for bedtime, the resident placed a foot down and fell forward, and both confirmed that the wheelchair leg rests were not present or applied at the time of transport. This failure to apply wheelchair leg rests during transport led to the resident’s foot contacting the floor and the subsequent fall and injury.
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