Failure to Use Wheelchair Foot Pedals During Staff-Assisted Transport
Penalty
Summary
Staff failed to ensure a safe environment free from accident hazards for a resident diagnosed with chorea and Alzheimer's disease. The resident, who had moderately impaired cognition and was generally independent with mobility, was observed being propelled in a wheelchair by staff without foot pedals in place. During this incident, the resident's feet were crossed and tucked under the seat, with one foot skimming the floor, increasing the risk of injury. The staff member stated that foot pedals were not used because the resident usually propelled himself, but at times, staff assistance was required for mobility. Further interviews confirmed that staff were expected to use foot pedals when propelling the resident in the wheelchair. The facility did not provide a policy regarding the safe transport of residents in wheelchairs. The lack of foot pedals during staff-assisted wheelchair propulsion constituted a failure to maintain a safe environment and prevent avoidable accidents for the resident.