Failure to Use Assistance Devices for Resident Transport
Penalty
Summary
The facility failed to ensure that two residents received the necessary assistance devices to prevent accidents, as required by their care plans and physician's orders. Resident 64, who was cognitively impaired and required assistance for personal care needs, was observed being transported without the required bilateral leg rests on her chair. This was contrary to the physician's orders and care plan, which specified that leg rests should be used for transport and outside. Nurse Aide 8 admitted to not applying the leg rests before transporting the resident. Similarly, Resident 120, also cognitively impaired and requiring assistance, was transported without the necessary leg rests. The resident's care plan and physician's orders indicated that standard leg rests should be used for transport and outside. Licensed Practical Nurse 9 transported the resident without leg rests, acknowledging that this was done because the resident was being disruptive. The Director of Nursing confirmed that the leg rests should have been used as ordered for both residents.
Plan Of Correction
Preparation and submission of this Plan of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Resident #64 and Resident #120 did not have any adverse reactions from being transported without leg rests. Resident #64 and Resident #120 will have, moving forward, leg rests on when being transported by staff. There were no other identified issues at the time of the survey. To prevent a future occurrence, the Director of Nursing/designee provided education to staff on the seating and positioning policy. The education included using wheelchair legs for transporting. To monitor and maintain ongoing compliance, the Director of Nursing/designee will complete an audit weekly x4 then monthly x2 to ensure staff transporting residents are utilizing leg rests. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.