Failure to Provide Physician-Ordered Wheelchair Leg Extender
Penalty
Summary
Staff failed to provide a physician-ordered leg extender for a resident who had undergone a below-the-knee amputation and was dependent on a wheelchair for mobility. The resident had a history of diabetes, vascular insufficiency, and recent surgical amputation, with orders from a vascular physician to keep the leg elevated and to use a wheelchair extender to prevent the leg from hanging down. Despite these orders, multiple observations over several days showed the resident self-propelling in the wheelchair with the amputated leg hanging down unsupported and no extender in place. Interviews with nursing and therapy staff revealed a lack of awareness regarding the physician's order for a leg extender. The registered nurse was not aware of the order, and the physical therapist had not assessed or measured the resident for a leg extender. The resident's care plan included instructions to elevate the leg and avoid tight compression, but there was no evidence that the necessary adaptive device was provided or that therapy had evaluated the need for the extender. The resident expressed concerns about redness and discoloration on the remaining foot, which was observed to have a purple area and flaking skin. Staff interviews confirmed that the resident did not have an extender and sometimes removed regular leg rests, but the specific extender ordered by the physician was never provided. Facility leadership, including the DON and Administrator, acknowledged that therapy should have assessed and provided the extender as ordered.