Failure to Use Wheelchair Foot Pedals During Resident Transport
Penalty
Summary
Facility staff failed to ensure safe wheelchair transportation for two residents with severe cognitive impairment and significant physical limitations. In one instance, a resident who was dependent on staff for all transfers and used a wheelchair for mobility was transported out of the dining room without foot pedals attached to the wheelchair. As the staff member pushed the resident over a threshold, the resident abruptly put both feet down on the floor, stopping the wheelchair's forward motion. The staff member then left to retrieve and apply the foot pedals before continuing transport. In another instance, a resident with hemiparesis and traumatic brain injury, who required staff assistance for transfers and used a wheelchair, was observed being pushed by a registered nurse without their feet placed on the foot pedals, even though the pedals were attached but folded away. The resident's feet skimmed over the floor during transport. Both staff and the Nursing Services Director confirmed that facility policy required foot pedals to be used during wheelchair transport to keep residents' feet off the floor, and this expectation was documented in the facility's Standards of Care.