Failure to Implement Wheelchair Leg Rest Care Plan Intervention
Penalty
Summary
The facility failed to implement care plan interventions for a resident with multiple sclerosis, dementia, anxiety disorder, and major depressive disorder, who had moderate cognitive impairment and limited physical mobility. The resident's care plan required extensive assistance from one staff member for locomotion using a standard wheelchair with bilateral footrests as needed. After a fall incident in which the resident's foot became caught under the wheelchair while being pushed, the care plan was revised to ensure leg rests were always attached when the resident was in the wheelchair. Despite this revision, observation revealed that the resident was seated in the wheelchair without leg rests attached. Interviews with the resident, an LPN, and the DON confirmed that the resident was not self-propelling and that facility policy required footrests for residents unable to self-propel. The staff failed to follow the care plan and facility policy, resulting in the resident being without the required leg rests at the time of observation and at the time of the fall.