Failure to Use Wheelchair Foot Pedals During Resident Transport
Penalty
Summary
Staff failed to appropriately and safely transfer two residents who required assistance with mobility. One resident with Parkinson's Disease, severe cognitive impairment, and a history of falls was observed being pushed in a high back wheelchair without foot pedals, with her feet near the floor, as she was transported approximately 60 feet from her room to the dining room. The resident's care plan indicated a risk for falls, limited mobility, and dependence on staff for wheelchair propulsion. Another resident with Alzheimer's Disease, dementia, severe cognitive impairment, and muscle weakness was also observed being pushed in a wheelchair without foot pedals, with the bottom of her feet brushing the floor during transport for about 50 feet. Both residents' care plans documented the need for staff assistance with wheelchair use and highlighted their fall risks. During interviews, the DON confirmed that foot pedals should be used whenever staff transport residents in wheelchairs, and the Administrator reported the facility lacked a policy for transporting or pushing residents in wheelchairs.