Failure to Use Wheelchair Foot Pedals and Inconsistent Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that foot pedals were utilized when residents were transported in wheelchairs and did not consistently implement fall prevention interventions for several residents. Multiple observations revealed that staff pushed residents in wheelchairs without foot pedals, requiring residents to hold their feet above the floor during transport. This occurred despite the facility's policy and repeated staff education on the requirement of using foot pedals during wheelchair transport. In several instances, staff acknowledged that the 'no pedals, no push' rule was not always followed, particularly by new staff members. For one resident with severely impaired cognition and a history of right hemiparesis due to a cerebrovascular accident, the care plan included specific fall prevention interventions such as the use of Dycem in the wheelchair, removal of the sling after transfers, and use of non-skid footwear. However, the resident experienced multiple falls, including one where he was found on the floor with a head laceration and another where he slid out of his chair while the sling was still under him. Observations and interviews confirmed that interventions like Dycem and gripper socks were not consistently in place at the time of these incidents. Other residents, including one with intact cognition and another requiring moderate assistance with transfers, were also observed being transported in wheelchairs without foot pedals. Staff interviews and documentation confirmed that these safety interventions were not reliably implemented, despite being included in care plans and discussed in staff education sessions. The facility census at the time was 88 residents.