Failure to Ensure Proper Wheelchair Positioning
Penalty
Summary
Staff failed to ensure proper wheelchair positioning for a resident diagnosed with Parkinson's disease, who had varying levels of cognitive impairment and required assistance with activities of daily living. The resident's care plan indicated a need for limited assistance with wheelchair mobility, but electronic medical records showed she required partial to total staff assistance for mobility. Despite this, observations on multiple occasions revealed the resident's feet were not properly positioned on the wheelchair foot pedals, with her heels elevated above the pedals and toes pointed downward. Interviews with CNAs and nursing staff confirmed that the resident's feet did not fit properly on the foot pedals and that this had been an ongoing issue. Staff acknowledged that the resident's feet often came off the pedals and that the pedals did not accommodate her feet appropriately. The facility did not provide a policy regarding wheelchair positioning, and no evidence was presented that the issue had been addressed prior to the survey.