Failure to Provide Wheelchair Leg Rest Support for Resident with Lower Extremity Impairment
Penalty
Summary
A resident with multiple medical conditions, including peripheral vascular disease, a stage four pressure ulcer, contracture of the right knee, hemiplegia, and an above-knee amputation, was observed on several occasions sitting in a wheelchair without a supportive leg rest or footrest. The resident was seen propelling himself in the hallway and sitting in various areas of the facility with his right lower extremity elevated and unsupported, despite having a care plan intervention to elevate his legs when sitting. The resident reported that he had a leg rest with an attached footrest but was unable to attach it himself and did not receive assistance from staff. Staff interviews confirmed that the resident should not be positioned in his wheelchair without the leg rest/footrest due to his medical conditions, including an ankle ulcer and contracture. The DON stated she was unaware that the device was not attached and that it was the responsibility of nursing staff to ensure the leg rest/footrest was applied daily. The failure to provide and secure the supportive device as required resulted in the resident repeatedly being left without necessary support for his lower extremity.