Resident Injury Due to Improper Positioning and Operation of Broda Chair
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a Broda chair was positioned and operated safely during resident care, resulting in a resident sliding from the chair and sustaining a fracture. The resident involved had multiple diagnoses, including hemiplegia and hemiparesis following intracerebral hemorrhage, cerebral infarction, osteoarthritis, type 2 diabetes, fibromyalgia, and macular degeneration, and had a BIMS score of 12, indicating moderate cognitive impairment. The resident’s care plan documented dependence on staff for all transfers with a Hoyer lift, non-ambulatory status, and the need for staff assistance for all mobility while seated in a Broda chair. On the evening in question, a CNA leaned the resident forward in the Broda chair to check the placement of the Hoyer lift sling and to change the resident’s blouse. During this care, the resident slid forward out of the chair and landed on their knees. Nursing documentation and an RN assessment completed immediately after the incident noted that the seat of the Broda chair was tilted forward, with the front edge lower than the back edge and not parallel to the ground, creating unsafe positioning during care. In a subsequent phone interview, the CNA involved confirmed that the resident slid out of the Broda chair after the CNA tilted the seat too far forward. Following the incident, the resident reported pain and bruising to the right lower extremity, and diagnostic imaging confirmed a recent fracture of the distal shaft of the right fibula. The resident was transported to a local hospital for further evaluation and returned with a plaster splint applied to the right foot and ankle. The resident later reported that they slid out of the Broda chair because the seat was tilted too far forward and described experiencing significant pain as a result of the injury. Facility leadership, including the DON and NHA, confirmed the findings related to the unsafe positioning and operation of the Broda chair during care.
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