Failure to Include Foot Pedal Use in Resident's Care Plan
Penalty
Summary
The facility failed to complete a comprehensive care plan for one resident, specifically omitting staff instructions regarding the use of foot pedals when propelling the resident in his wheelchair. The resident had diagnoses of chorea and Alzheimer's disease, with a BIMS score indicating moderately impaired cognition. Documentation showed the resident was generally independent with his wheelchair and walker, but at times required staff assistance for mobility. The care plan noted the resident's jerking movements and independence with a walker but did not address the use of foot pedals during staff-assisted wheelchair propulsion. Observations revealed that staff propelled the resident in his wheelchair without foot pedals, with the resident's feet crossed and tucked under the seat, and the toe of his left foot skimming the floor. Staff interviews confirmed that while the resident usually propelled himself, he sometimes needed staff assistance, at which point foot pedals were expected to be used. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timeframes, but the care plan lacked specific instructions for staff regarding foot pedal use during assisted wheelchair mobility.