Failure to Use Wheelchair Leg Rests During Resident Transport
Penalty
Summary
A deficiency occurred when a resident with cognitive impairment and a diagnosis of cerebral palsy, who required assistance for daily care and used a specialized wheelchair with leg rests per care plan, was transported without the required leg rests. Facility policy states that wheelchair footrests are necessary to support the legs and prevent feet from getting caught under the wheelchair, which could result in a fall. Despite this, a nurse aide pushed the resident in the wheelchair to the dining room without the leg rests attached. During the transport, the resident's foot became caught under the wheelchair, causing the resident to fall out of the chair onto his hands and knees. Staff interviews and facility investigation confirmed that the leg rests were not used as required by the resident's care plan, and the Director of Nursing acknowledged that footrests should have been in place during transportation.
Plan Of Correction
Resident R50 was not injured at the time of the incident. Nurse aide 2 was suspended at the time of the incident as part of the facility's self-reported investigation for failure to follow facility policy. All staff were re-educated on the facility policy regarding use of leg rests while in a wheelchair. The Director of Nursing or designee will complete daily random observation audits of residents being transported in their wheelchairs to ensure safe practice. Audits will be completed daily x5 for 2 weeks, then weekly x4, then monthly x2, with results to Quality Assurance.