Failure to Use Wheelchair Footrests and Report Incident Leads to Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe wheelchair transport and timely reporting of an accident, resulting in injury to a dependent resident. The resident had diagnoses including congestive heart failure, chronic kidney disease stage III, paroxysmal atrial fibrillation, lymphedema, chronic venous insufficiency of the lower extremities, unsteady gait, muscle wasting, and difficulty walking, and was documented on the MDS as cognitively intact but totally dependent on staff for wheelchair propulsion. On the day of the incident, two CNAs used a sling-type mechanical lift to transfer the resident to a manual wheelchair, and one CNA then transported the resident to be weighed without applying the wheelchair footrests. As the CNA pushed the wheelchair onto and off the scale, the resident slipped down in the chair and her left foot became caught in the left front wheel under the wheelchair. The resident reported saying she was tangled and expressed pain, and the CNA acknowledged hearing an “ouch” and knowing she should have used the foot pedals. Following the incident, the CNA did not report the event to nursing staff or supervisors, contrary to the facility’s Accident/Incident and Unusual Occurrence Policy that requires all employees to report any accident or incident that has or could have resulted in injury. The facility remained unaware of the wheelchair incident until after a left tibia fracture was diagnosed. In the interim, progress notes documented that the resident reported left knee swelling and bruising that had been present for three days, with pain and increasing difficulty with movement. The NP, not informed of any trauma, initially assumed the symptoms were related to the resident’s history of cellulitis, lymphedema, and vascular insufficiency and treated accordingly, later stating that knowledge of the trauma would have prompted an order for an X-ray. The NP indicated it was likely that the twisting of the resident’s foot under the wheelchair caused the leg fracture, and the DON confirmed that the incident was only reported after the fracture was identified.
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