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F0689
D

Failure to Provide Adequate Supervision During Wheelchair Transport

Pittsburgh, Pennsylvania Survey Completed on 06-06-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate supervision to prevent a fall from a wheelchair for one resident. The resident in question had multiple diagnoses, including dementia, anxiety, blindness, difficulty walking, cognitive and communication deficits, and agitation, and was also on blood thinners. The resident required a manual wheelchair and needed partial to moderate assistance to move it. Occupational therapy notes indicated the resident needed frequent adjustments for lateral supports due to leaning and falling asleep in the wheelchair. On the day of the incident, a nurse aide attempted to redirect the resident's wheelchair from behind, during which the resident put her feet down and subsequently fell forward out of the wheelchair. Staff statements and documentation confirmed that the resident could not propel herself and that leg rests were not provided, as therapy determined they would interfere with independence for residents who could self-propel. The facility did not have a specific policy for transporting residents in wheelchairs, and staff relied on the electronic kardex for resident-specific care needs. The nurse aide involved reported that she was pushing the resident, who then put her feet down and fell forward. Other staff confirmed the resident was unable to propel herself and did not have leg rests. The facility's administration acknowledged, after reviewing CCTV footage, that the aide continued to push the wheelchair after the resident's feet were down, resulting in the fall. The facility was unable to produce the resident's plan of care prior to the incident, but the current plan of care identified the use of leg rests.

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