Failure to Prevent Accident Hazards and Ensure Safe Wheelchair Use
Penalty
Summary
The facility failed to ensure that areas were free from accident hazards and did not provide adequate supervision to prevent accidents for multiple residents. One resident with dementia and weakness, who was dependent on staff for wheelchair mobility and had moderately impaired cognition, was observed being transported in a wheelchair with her feet not consistently on the foot pedals. Staff confirmed that her feet did not always stay on the pedals during transport, and the facility did not have a policy regarding wheelchair positioning or foot pedal use. Another resident with a history of falls, memory impairment, and confusion, who was on hospice services, experienced a fall while attempting to retrieve an item from her bedside table. The care plan for this resident included reminders to use the call light and wait for staff assistance, but lacked further interventions after the fall. Staff interviews indicated that the intervention of re-educating the resident to use the call light was not appropriate given her cognitive status, and that she often got up without waiting for help despite the call light being within reach. A third resident with severe cognitive impairment and peripheral vascular disease was observed being pushed in a wheelchair without foot pedals. Staff acknowledged that foot pedals should be used when assisting residents in wheelchairs, but in this case, the pedals were not available. The facility did not provide a policy for wheelchair positioning, including the use of foot pedals, and staff interviews confirmed inconsistent practices regarding their use.