Failure to Implement Therapy-Recommended Wheelchair Leg Rests in Care Plan
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple medical conditions, including edema, gout, and rheumatoid arthritis. The resident, who had severely impaired cognition and required a wheelchair for mobility, was recommended by physical therapy to use a standard wheelchair with bilateral leg rests. However, the care plan did not include this recommendation, and the resident was repeatedly observed sitting in a wheelchair without leg rests, with their feet dangling and not touching the floor. Interviews with facility staff, including a CNA, LPN, RN Unit Manager, and the Director of Rehabilitation Services, confirmed that leg rests should have been used as per therapy's recommendation and facility policy, especially since the resident's feet did not reach the floor and they spent most of their time in the wheelchair. Staff acknowledged that the absence of leg rests could contribute to discomfort and exacerbate the resident's existing conditions. Despite these findings and documented recommendations, the necessary intervention was not included in the care plan or implemented in practice.