Failure to Use Wheelchair Foot Pedals During Assisted Locomotion
Penalty
Summary
A deficiency occurred when a Certified Nurse Aide (CNA) assisted a cognitively impaired resident with wheelchair locomotion in the hallway without the use of wheelchair foot pedals. The resident, who had diagnoses including dementia, long-term use of anticoagulants, and generalized muscle weakness, was documented as having severely impaired cognition and a history of falls with fractures. The resident's care plan specifically instructed staff to lock the wheelchair for all transfers and to position the resident's feet on the foot pedals for all assisted wheelchair locomotion. During the observed incident, the CNA assisted the resident without the foot pedals installed, requiring the resident to hold her feet off the floor while being moved. Interviews with facility staff, including a Licensed Nurse and an Administrative Nurse, confirmed that the standard practice and facility expectation was for all residents to have foot pedals installed and their feet placed on the pedals prior to assisted wheelchair locomotion. The facility had bags attached to wheelchairs for pedal storage, but staff failed to follow the established expectation. Additionally, the facility did not have a written policy regarding the use of wheelchair pedals, relying instead on standard practice. The failure to use foot pedals during assisted locomotion constituted an environment not free from accident hazards and did not provide adequate supervision to prevent accidents.