Failure to Use Wheelchair Foot Pedals During Resident Transport
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe wheelchair transport by not using foot pedals for a resident who required assistance with mobility. Resident #8 had moderately impaired cognition, with a BIMS score of 12/15, and diagnoses including diabetes mellitus, partial paralysis, and non-traumatic brain dysfunction. The resident’s MDS indicated dependence or need for assistance with most mobility tasks, including transfers, bed mobility, and all other forms of mobility, and documented use of a wheelchair and walker. The resident’s care plan did not identify any non-compliance with wheelchair foot pedal use. On the observed date and time, an LPN (Staff A) attempted to wake the resident, who was seated in a wheelchair at the dining room table and was lethargic, requiring multiple taps or grabs of the left arm to elicit a response. Staff A then transported the resident in the wheelchair without foot pedals to a hallway area with more sunlight. Subsequent interviews with an RN (Staff D), another LPN (Staff E), and the ADON confirmed that staff understood residents should not be transported in wheelchairs without foot pedals and that feet should be on the pedals during transport unless the resident is self-propelling. Staff A acknowledged that foot pedals should have been applied during the transport. The facility did not have a policy that provided staff directives for transporting residents in wheelchairs.
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