Failure to Use Wheelchair Footrests During Resident Transport
Penalty
Summary
Facility staff failed to safely transport six residents in wheelchairs by not ensuring the use of footrests during movement throughout the facility. Multiple observations documented staff, including CNAs and an activities aide, pushing residents in wheelchairs without footrests attached or without the residents' feet placed on the footrests. In several instances, residents' feet were observed dragging on the floor while being transported, and in one case, a resident was wearing grip socks while her foot dragged. These actions occurred in various locations, such as from dining rooms to nurses' stations, down hallways, and to resident rooms. The residents involved had significant medical histories, including Alzheimer's disease, unsteadiness on their feet, muscle weakness, history of falls, dementia, epilepsy, and left-sided weakness following a stroke. All residents reviewed for this deficiency were noted to be severely cognitively impaired, as indicated by low BIMS scores. Staff interviews confirmed that facility policy requires residents' feet to be securely on footrests when being pushed in wheelchairs, but this was not followed during the observed incidents.