Failure to Ensure Safe Wheelchair Locomotion
Penalty
Summary
Staff failed to ensure safe wheelchair locomotion for a resident diagnosed with Alzheimer's disease and muscle weakness, who was dependent on staff for mobility. Multiple direct observations showed a certified nurse aide (CNA) pushing the resident in a wheelchair without both feet properly placed on the foot pedals. The resident's feet were seen dragging on the floor in socks, sometimes erratically kicking, and at one point nearly being run over by the wheelchair wheels. These incidents occurred during transfers between the living room and dining room, and while moving the resident between tables. Interviews with several staff members, including CNAs and a certified medication aide, confirmed that facility protocol requires residents' feet to be elevated on foot pedals during wheelchair movement to prevent injury. Staff acknowledged awareness of the proper procedure and the risks associated with non-compliance, such as falls and abrasions. The Director of Nursing also confirmed the expectation that staff ensure residents' feet are on the foot pedals during wheelchair locomotion. The facility was unable to provide a written policy regarding wheelchair locomotion during the survey.