Failure to Timely Assist Residents and Provide Wheelchair Foot Pedals
Penalty
Summary
The facility failed to timely assist a resident with mobility and incontinence care, as well as failed to provide necessary wheelchair foot pedals for another resident, resulting in unmet needs for both individuals. One resident, who was moderately cognitively impaired and dependent on staff for transfers and mobility, requested to be changed and to get out of bed. Despite asking his assigned CNA for assistance, he remained in bed for several hours, with staff citing the unavailability of a Broda chair and competing priorities as reasons for the delay. The resident continued to wait for assistance, expressing his needs to both staff and the surveyor, and was not assisted out of bed until much later in the day. Another resident, also moderately cognitively impaired and with significant lower extremity impairment, returned from a doctor appointment in a manual wheelchair without foot pedals. His elderly brother had to pull the wheelchair backwards through the facility, causing the resident distress and fear, as his feet dragged on the floor. The resident reported having repeatedly requested foot pedals for several days without receiving them. Staff interviews confirmed that foot pedals were not readily available or installed, and that the resident was typically pushed backwards in the wheelchair due to the lack of footrests. Staff interviews further revealed a lack of clear procedures for ensuring wheelchair foot pedals were available and installed, as well as inconsistent understanding of when residents required such equipment. The maintenance director indicated that foot pedals were stored in various locations, making them difficult to locate, while the DON acknowledged that residents should not be pulled backwards in wheelchairs. These failures resulted in the residents' needs and requests not being accommodated in a timely and appropriate manner.