Failure to Ensure Proper Wheelchair Transport
Penalty
Summary
The facility failed to ensure that a resident's wheelchair was equipped with two foot pedals during transport, which is necessary to prevent accidents. Resident #17, who has severe cognitive impairment and uses a manual wheelchair, was observed being pushed by staff with only one foot pedal attached. This occurred on multiple occasions, with staff members acknowledging the need for two foot pedals but continuing to transport the resident with only one. The resident's medical history includes non-Alzheimer's dementia, hemiplegia or hemiparesis, arthritis, and a hip fracture, which further necessitates proper support during wheelchair transport. Interviews with staff revealed that the second foot pedal was broken, and there was no policy in place for wheelchair transport. Staff members were aware of the broken pedal but continued to transport the resident without addressing the issue. The Director of Nursing confirmed the need for two foot pedals when pushing the resident, especially since the resident could not keep her feet on one pedal. Despite this, the facility did not have a policy to guide staff on proper wheelchair transport, contributing to the deficiency.