A resident who was dependent on staff for wheelchair mobility and had multiple medical conditions was transported by a housekeeper without leg rests attached to the wheelchair. During transport, the resident's foot became caught in the wheel, leading to a forward fall onto the pavement and resulting in multiple injuries, including a laceration that required suturing. The staff member was unaware of the requirement for leg rests, and no transport policy was provided.
A resident with impaired vision and a powered w/c fell after driving off a curb and sustained a serious leg fracture requiring hospital and surgical repair. The resident had an indoor mobility assessment that noted need for staff help with ramps, backing up, and obstacles, but the facility did not reassess after a new powered w/c was obtained, did not develop a w/c care plan, and did not complete the incident investigation within the required timeframe or obtain witness statements.
The facility failed to honor resident choice regarding mobility and privacy. One resident with major depressive disorder and intact cognition had her power wheelchair removed despite prior documentation that she was cognitively and functionally able to use it, and no resident-centered plan, timeline, or communication was documented to facilitate its return; this led to frustration, anxiety, mental anguish, and self-isolation with psychological harm. Another resident with CIDP and major depressive disorder, care planned for a motorized wheelchair, was told before admission that electric wheelchairs were no longer allowed and was not permitted to use his own device, including for VA visits. A third resident with severe cognitive impairment was not allowed to close her door at night despite repeatedly expressing a preference for a quiet, dark environment for sleep, with staff insisting the door remain open for safety even though the items she placed behind the door were light and easily movable, and the DON later acknowledging the resident’s right to close her door.
A resident with cerebral palsy, cognitively intact but dependent for all ADLs and using a wheelchair for mobility, was being unloaded from a facility van when the transportation driver, distracted by an outdoor event, pushed the wheelchair backward toward the rear door while the mechanical lift was still fully lowered and not in place at the door. The wheelchair fell about three feet to the ground, causing a forearm laceration and an acute fifth metatarsal fracture. Facility policy required the lift to be raised and in position before moving a wheelchair onto it, and observations of other drivers showed correct procedures included securing the lift, locking wheelchair brakes, and responding to the van’s door alarm and warning light when weight is present without the lift engaged.
A resident with morbid obesity and depression, who required a WC for mobility and staff assistance for transfers and showers, was not provided with an appropriately sized WC or safe shower equipment. Despite care plan goals for the resident to get out of bed and socialize, records showed only one shower over several weeks and no documented WC assessment by therapy or nursing. The administrator and ADON confirmed that two bariatric WCs obtained did not fit, no additional WC was secured, and no suitable shower chair was available. CNAs reported the resident could not access the shower room, was bathed in bed, and had to sit on the side of the bed to eat, and observation showed the resident could not sit safely or comfortably in the available bariatric WC.
A resident who required substantial assistance for mobility and was dependent on nursing care was transferred into an incorrect high back wheelchair without suitable footrests, rather than her prescribed standard wheelchair. While being moved from a dining room table, she fell forward out of the chair, sustaining facial and upper extremity fractures. Staff and therapy assessments confirmed the wheelchair was inappropriate for her needs, and the facility's fall management policy was not followed.
A resident with COPD, heart failure, rheumatoid arthritis, moderate cognitive impairment (BIMS 9), and wheelchair dependence was transported by facility staff to an outside medical appointment when the wheelchair was not properly secured in the facility van. CNAs reported using the van’s securement system but did not use any checklist to verify correct application; during transit they heard a noise and found the resident on the van floor with the wheelchair on its side and the seatbelt no longer in place. The resident reported hitting the head and having head pain. The facility’s investigation and QAPI review determined that the wheelchair straps had not been appropriately placed to firmly secure the chair, while the maintenance review found the securement equipment itself intact and functioning. The resident was evaluated in a hospital ED for fall and head injury and treated with an over-the-counter analgesic after imaging showed no new diagnoses.
A resident with severe cognitive impairment and declining mobility was allowed to self-propel in a facility wheelchair without proper assessment, fitting, or supervision. Staff did not evaluate the safety or appropriateness of the wheelchair, nor did they update the care plan or refer for physical therapy despite documented functional decline. This led to the resident's legs becoming entangled in the wheelchair, resulting in fractures and hospitalization.
A resident with impaired mobility and a history of falls sustained a head laceration after falling from a wheelchair lift during transport. The staff member operating the lift did not follow manufacturer safety guidelines, failed to ensure the resident was properly secured, and left the resident unattended on the lift. Incomplete staff training documentation and lack of adherence to facility policy on wheelchair securement contributed to the incident.
A resident who required maximal assistance for transfers was transported in a facility van without a seatbelt or appropriate safety restraint, as none was available to fit her wheelchair. During the trip, the van hit a bump, causing the resident to slide out of her wheelchair and sustain a fractured femur, requiring hospitalization and surgery. Staff were aware of the lack of a suitable safety device, and facility policy requiring seatbelt use during transport was not followed.
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