Failure to Revise Care Plan for Resident Wheelchair Mobility Needs
Penalty
Summary
The facility failed to revise the care plan to address a documented decline in mobility for a resident with progressive multiple sclerosis (MS). The resident was observed attempting to self-propel a wheelchair while dragging the right foot, which inhibited movement, and the wheelchair had no leg rests installed at that time. The existing care plan intervention for wheelchair mobility, last revised on 1/12/25, did not include the use of wheelchair leg rests to improve the resident’s ability to self-propel. A licensed nursing assistant (LNA) reported awareness that the resident sometimes had difficulty self-propelling because the resident’s feet became tangled, and stated this concern had been reported to a nurse. An occupational therapist (OTR) also stated she was aware of the resident’s feet dragging and had provided leg rests for the wheelchair and educated staff to use them, noting the resident had sufficient upper body strength to self-propel when leg rests were in place. The OTR could not confirm that this intervention had been incorporated into the care plan. A subsequent observation showed the wheelchair with leg rests attached, but review of the care plan confirmed it still had not been revised to include the use of leg rests.
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