Failure to Apply Wheelchair Foot Pedals During Resident Transport
Penalty
Summary
Staff failed to ensure that foot pedals were applied to residents' wheelchairs during transport for two residents. One resident, who had severely impaired cognition and multiple diagnoses including end-stage renal disease, Alzheimer's disease, COPD, and reduced mobility, was observed being transported in a wheelchair without foot pedals by a CNA. The resident's care plan indicated use of a manual wheelchair for long distances, and staff later acknowledged that pedals should have been used but were not considered due to the resident's usual independence with mobility. Another resident, with moderately impaired cognition, end-stage renal disease, non-Alzheimer's dementia, diabetes, and gait abnormalities, was also observed being transported in a wheelchair without foot pedals. This resident's care plan noted use of a wheelchair at times and a preference for only one pedal. Staff confirmed that all residents should have pedals when transported and that the resident's wheelchair had only one pedal per her request. The DON stated that staff should offer pedals and document any refusals. Facility policy required staff to be trained on accident hazards and to prevent avoidable accidents.