Failure to Ensure Wheelchair Foot Pedals During Resident Transport
Penalty
Summary
The facility failed to provide adequate supervision and ensure the use of assistive devices to prevent accident hazards for three residents who were identified as high fall risks. Observations revealed that these residents were transported in their wheelchairs without foot pedals attached, resulting in their feet dangling or dragging on the floor during movement. This occurred on multiple occasions and involved both nursing and non-nursing staff members pushing the residents without the required safety equipment in place. Resident records indicated that all three individuals had significant medical histories, including recent fractures, muscle weakness, dementia, and a history of falls. Their care plans and fall risk assessments identified them as high risk for falls and included various interventions, but none specified the need to ensure foot pedals were attached to their wheelchairs during transport. This omission left a gap in their fall prevention strategies. Interviews with facility leadership confirmed that staff were expected to use foot pedals when transporting residents in wheelchairs. The DON and DOR both acknowledged the importance of this practice for resident safety, with the DOR specifically noting the risk of residents falling forward if their feet were left dangling or dragging. Despite these expectations, the deficiency persisted due to the lack of specific interventions in care plans and failure of staff to consistently implement safety measures during resident transport.