Failure to Ensure Use of Wheelchair Footrests During Resident Transport
Penalty
Summary
The facility failed to ensure safe mobility for residents by not requiring the use of footrests on wheelchairs when staff transported residents. This deficiency was observed in four out of six residents reviewed for safety. In one incident, a resident with multiple diagnoses including vascular dementia, encephalopathy, and muscle weakness was being pushed in a wheelchair without footrests. The resident planted her feet on the floor, resulting in her falling forward out of the wheelchair and sustaining a laceration to her forehead that required three sutures. Staff interviews confirmed that the resident did not have foot pedals assigned to her wheelchair, and the CNA involved did not follow the facility's stated rule for resident safety regarding footrests. Additional observations revealed that other residents were also transported in wheelchairs without footrests. One CNA was seen pushing a resident into the dining room without footrests in place and admitted to forgetting to use them, despite acknowledging that footrests should be used for safety. Another LPN pushed a resident whose foot was sliding across the floor due to the absence of footrests and stated that foot pedals are supposed to be used when pushing residents. Staff consistently reported that footrests are stored in blue bags on the back of wheelchairs and should be used during transport, but this practice was not consistently followed. The facility did not have a written policy specifically addressing the use of footrests on wheelchairs, although staff training and in-service education indicated that all residents using wheelchairs must have foot pedals in place when being pushed. The lack of adherence to this expectation, combined with the absence of a formal policy, contributed to unsafe conditions and resulted in at least one resident injury. Interviews with the administrator and DON confirmed that while staff were trained on the importance of using footrests, there was confusion regarding the existence of a formal policy, and the practice was not consistently enforced.