Failure to Ensure Safe Wheelchair Transport and Equipment Maintenance
Penalty
Summary
The facility failed to ensure the use of foot pedals during wheelchair transport and did not maintain mobility equipment in good working order, resulting in deficiencies for three residents. One resident with moderately impaired cognition and dependent on staff for wheelchair propulsion was observed being pushed in her wheelchair without foot pedals, causing her feet to lightly touch the ground. Another resident, who had functional limitations in both lower extremities and was at risk for falls, was also transported in a wheelchair without foot pedals. The resident reported that the pedals were often left in his room because they got in the way at the dining table, and there was no bag on the wheelchair to store them. Staff interviews confirmed that missing foot pedals was a recurring issue, and there was no facility policy regarding their use. A third resident, with a history of falls and recent fractures, experienced a fall when his walker collapsed during a transfer from chair to bed. Documentation revealed that the walker was in poor condition with missing screws, and staff confirmed that the equipment was not safe for use. The resident had been permitted by therapy to transfer independently, and the incident was reported to the ADON. The facility's process for monitoring and maintaining equipment safety was not effectively implemented, as evidenced by the use of a defective walker.