Failure to Ensure Safe Wheelchair Transport and Resident Monitoring
Penalty
Summary
The facility failed to prevent accident hazards by not ensuring safe transportation of a resident in a wheelchair and by not adequately monitoring another resident known for pocketing food. Specifically, a 61-year-old resident with multiple diagnoses including unsteadiness, difficulty walking, dementia, and muscle weakness was observed being pushed in a wheelchair without foot pedals by staff on two separate occasions. The resident's care plan indicated that staff could assist with wheelchair propulsion as needed, and facility staff interviews confirmed that the standard practice is to use foot pedals when pushing residents in wheelchairs. However, both direct observation and staff statements revealed that this protocol was not followed, and the facility did not have a written policy addressing this issue, relying instead on orientation materials and standard practice. Additionally, the report notes that the facility failed to monitor a resident known for pocketing food during meals, though the detailed findings focus primarily on the wheelchair transport issue. Staff interviews and a review of orientation materials confirmed that the expectation is 'No Pedals, No Push,' yet this was not adhered to in practice. The lack of a formal written policy and repeated non-compliance with established safety practices contributed to the deficiency.
Plan Of Correction
Element #1 ACTION TAKEN: Resident #34 will have a review of their person-centered plan of care for Locomotion with revisions made based on the review to ensure safe transportation occurs while in a wheelchair. Wheelchair foot pedals were provided to Resident #34. Resident #42 will have a review of their person-centered plan of care to ensure safe monitoring is provided during meals and reflected on the plan of care with revisions made based on the review. Element #2 IDENTIFICATION OF OTHER RESIDENTS: Residents residing at the facility requiring assistance for wheelchair mobility have the potential to be affected and will be identified through the care plan item listing report for locomotion. Identified residents will have a review of their person-centered plan of care for Locomotion with revisions made based on the review to ensure safe transportation occurs while in a wheelchair. An audit will be conducted to validate residents requiring assistance for wheelchair mobility have foot pedals available for use. Residents that pocket food have the potential to be affected and will be identified through care plan review. The resident's person-centered plan of care will be reviewed to validate interventions are in place and utilized to promote safety monitoring during meals. ELEMENT #3: SYSTEMIC CHANGES: Lake Woods will provide reeducation to all staff by 5/26/2025 or prior to the next day worked in the case of the leave of absence, vacationing employee. The educational agenda will include the standard of practice while providing locomotion assistance in the wheelchair with the utilization of the foot pedals. Licensed nursing staff and certified nursing assistants will receive reeducation that residents who pocket food require supervision at meals, and the importance of offering fluids during meals. Examples will be provided when residents may decline assistance and examples of interventions for staff utilization to encourage the residents to accept assistance. ELEMENT #4: MONITORING: The Director of Health Care Services and/or designees will observe staff on various shifts as they provide assistance to residents with locomotion while in their wheelchair, including utilization of foot pedals 3-5 times a week for four weeks and periodically thereafter to evaluate effectiveness of the education that was provided. An additional observation will be completed during various mealtimes to ensure staff are providing monitoring of residents that are known to pocket food. This audit will be conducted 3-5 times a week for four weeks and periodically thereafter. The Director of Health Care Service will compile a report of this audit for review and recommendation by the Quality Assurance Performance Improvement Committee monthly times one (1) month and periodically thereafter. The Director of Health Care Services will assume responsibility for sustaining compliance.