Failure to Safely Transport Resident in Shower Chair Without Footrests
Penalty
Summary
The deficiency involves the facility’s failure to safely transport a cognitively intact resident with multiple medical conditions, including osteoarthritis, atherosclerotic heart disease, a history of poliomyelitis, dementia, and chronic kidney disease stage three, in a shower chair. On the morning in question, two CNAs transferred the resident from bed to the toilet and then from the toilet to a shower chair that did not have footrests, despite the resident having wheelchair footrests labeled with the resident’s name. Shortly after the transfer, as the CNA began to push the shower chair out of the resident’s room, the resident’s right foot slipped off due to the lack of footrests, caught on the floor, and rolled under the chair, causing the resident to cry out in pain and report right foot pain. Following the incident, the CNA immediately stopped pushing the chair, notified an RN, and the resident was returned to bed. The RN’s initial assessment did not reveal swelling or bruising, and a nurse practitioner was notified and ordered that the resident remain in bed, be placed on non-weight-bearing status for the right leg, and receive an x-ray. The x-ray was obtained the same day, and the initial results reported to the LPN and nurse practitioner indicated no fracture. During the remainder of that day and the following day, staff reported that the resident did not complain of pain but did not want to get out of bed. Subsequently, staff documented that the resident exhibited no pain until a later date when the resident began expressing excruciating right ankle pain. An LPN administered as-needed pain medication and notified the nurse practitioner, who ordered a stat x-ray of the right ankle. The x-ray showed minimally displaced acute or subacute fractures of the medial and lateral malleoli. Upon in-person assessment, the nurse practitioner noted the resident’s excruciating ankle pain and ordered transfer to the emergency room. The nurse practitioner stated that while the resident’s age and bone mineral density could have been contributing factors, the resident’s foot getting caught on the floor and rolling under the shower chair could have been a direct cause of the ankle fracture.
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