Failure to Ensure Functional Wheelchair Brakes During Assisted Transfer
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision to prevent a fall for one resident when staff attempted a transfer using a wheelchair with defective brakes. Clinical record review showed that Resident 3 had bilateral below-the-knee amputations and, per the Minimum Data Set assessment, required assistance for transfers between surfaces such as wheelchair to chair. On October 5, 2025, at 3:38 p.m., a nurse documented that the resident was being transferred from a wheelchair to a weight chair by two nurse aides (NA1 and NA2) when the wheelchair rolled out from under the resident and the resident was lowered to the floor. The nurse’s observation and facility fall documentation for that date identified that both wheelchair brakes were broken and did not fully engage prior to the transfer, allowing the wheelchair to move during the assisted transfer. In a subsequent interview, the Director of Nursing confirmed that staff should have ensured the wheelchair brakes were engaged and functioning so the wheelchair would not roll during the transfer. This deficiency was cited under 42 CFR 483.25(d) Accidents and referenced a prior citation on March 12, 2025, as well as 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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