Failure to Ensure Safe Wheelchair Transport for Resident
Penalty
Summary
A deficiency was identified when a resident with a history of repeated falls, bilateral upper limb carpal tunnel syndrome, and weakness was observed being pushed in her manual wheelchair by a CNA without wheelchair pedals attached. During this incident, the resident's feet were skimming the floor as she was transported down the hall. The resident confirmed she had requested to be pushed, and the CNA acknowledged knowing that wheelchair pedals should be used when pushing residents. The CNA was unsure if the resident even had pedals for her wheelchair, and another staff member, new to the facility, was unaware of the incident. The MDS documented that the resident was cognitively intact and typically propelled herself in the wheelchair or walked behind it. Facility policy, reviewed in October 2024, directs staff to position residents' feet on wheelchair footrests when needed and to ensure a safe environment for wheelchair mobility. The MDS coordinator and other staff interviewed understood that residents should not be pushed in wheelchairs without their feet on the pedals, as this could result in injury. The DON and LNHA acknowledged the concern when informed of the observation, and the nurse practitioner confirmed that the resident should not have been pushed with her feet skimming the ground.