Failure to Train Family Member on Safe Use of Broda Wheelchair Resulting in Resident Fall
Penalty
Summary
The facility failed to ensure a resident’s family member received proper training in the safe use of a Broda wheelchair, resulting in a fall. Resident 2, who had diagnoses including unsteadiness on feet and a vertebral compression fracture, had been using a Broda wheelchair in the facility. Her MDS showed a BIMS score of 13, indicating she was cognitively intact. On 12/16/25, while being wheeled by Family Member (FM) 1, Resident 2 fell from the Broda wheelchair and hit her face on the floor. In interviews, Resident 2 stated she fell hard, head first, and hurt all over, and further stated the fall could have been prevented if the facility had trained FM 1 on how to safely and properly wheel her in the Broda wheelchair. FM 1 also stated that the facility did not teach her how to properly use and wheel the Broda wheelchair. Record review and staff interviews showed there was no documented training for FM 1 on wheelchair safety prior to the fall, despite Resident 2’s use of the specialized Broda wheelchair. The SBAR note documented the witnessed fall while FM 1 was wheeling the resident. During review of Resident 2’s care plan and progress notes, the PT confirmed that Resident 2 had been using a Broda wheelchair and that there was no documentation that FM 1 was trained on its use, and also could not find a care plan addressing the resident’s safety while using the Broda wheelchair. The MDS Coordinator likewise confirmed there was no care plan on the safe use of the Broda wheelchair. The DON stated the facility did not have a policy and procedure on the use of the Broda wheelchair.
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