{"Short_Answer__76":"201904741","Date__77":"07\/24\/2019","Multiple_Choice__78":"Scott Schifsky","Multiple_Choice__79":"Marilee Bengtson","Short_Answer__80":"Thomas Allen","Short_Answer__81":"Chet Whitmore","Short_Answer__82":"chet.whitmore@thomasalleninc.com","Multiple_Choice__84":"Wheelchair Safety","Multiple_Choice__85":"Hennepin County","Date__86":"06\/27\/2019","Free_Text__87":"On 6\/27\/2019 between 8:00am and 9:30am, Staff 1 was driving person in their electronic wheelchair.  Staff 1 ran into door way, and the person\u2019s leg got caught. The person\u2019s leg looked swollen, so Reporter told Program Manager to bring VA to an Urgent Care (unknown information.) Reporter notified Guardian, Case Manager (unknown information,) and County Licensor. Urgent Care Physician (unknown information) told Program Manager to bring VA to an ER. Program Manager brought VA to an ER (unknown information,) and VA has a hairline fracture in VAs' foot (unknown information.) VA was admitted to Hospital (unknown information.) Reporter is waiting to hear back to see what plan of action Hospital plans to take. Reporter will train AP on how to drive VAs' wheelchair.","Multiple_Choice__96":"1","Short_Answer__91":"Staff did not have foot pedals on person\u2019s wheelchair while driving the person to the restroom.","True_or_False__94":"Yes","Date__97":"09\/05\/2019","Free_Text__98":"Staff arrived at 6:00am and described the morning as a typical shift.  Staff took a Benadryl for allergy relief at 5:00am and described that the medication did not make her sleepy.  Staff then assisted the person with their morning routine by helping them use the restroom, bathing, and then going to the kitchen for breakfast.  The person has difficulty swallowing food and requires assistance eating and reminders to swallow twice.  Staff was doing a variety of household tasks and was helping people get ready between 6:00am and 8:00am.  There were three staff on duty that morning. \r\n\r\nAfter breakfast staff then assisted the person by driving her electric chair from the kitchen to the restroom without foot pedals.  The person does not like their foot pedals on the chair.  The person has a lot of rigidity in her muscles and her legs were sticking out the sides of the chair.  Staff stopped shortly before the doorway to do a task and then proceeded driving the person in their chair.  The person\u2019s leg broke when their foot got caught on a cupboard door jam.","Free_Text__100":"Agency staff not having foot pedals on while driving the person\u2019s wheelchair was influenced by the staffs\u2019 divided attention.  Staff could not recall the specific task that divided her attention while being midway through the kitchen. The person had a preference against using foot pedals and communicates their preference by their rigidity and loud vocalizations.  This was further complicated by typical morning routine that resembles the practice of most busy group homes.  Additionally the staff pushing the wheelchair had a number of years of experience working with the person and felt more comfortable pushing the person without foot pedals. Furthermore, there were policies and plans that were conflicting related to wheel chair. The provider had a policy to always use foot pedals with wheelchairs for safety, but had also been pushing person-centered practices to support people they serve to have more control of daily decisions. \r\n\r\nThe CSSP and risk management plan followed standard wheelchair safety and practice related to the wheelchair manufacturer guidelines.  The general practice for wheel chair use conflicted with the agency\u2019s practice. Team conversations about how this person wanted to live did not have consistency with the person\u2019s plan and guidelines related to wheelchair use. There was a practice of the home not to use foot pedals and given the numerous tasks in the morning, staff could not account for everything.","Multiple_Choice__101":"0","Multiple_Choice__103":"0","Multiple_Choice__105":"0","Multiple_Choice__107":"0","Multiple_Choice__109":"0","Multiple_Choice__111":"0","Multiple_Choice__113":"0","Multiple_Choice__115":"2","Free_Text__116":"Agency staff not having foot pedals on while driving the person\u2019s wheelchair was influenced by the staffs\u2019 divided attention.  Additionally the staff pushing the wheelchair had a number of years of experience working with the person and felt more comfortable pushing the person without foot pedals. Furthermore, there were policies and plans that were conflicting related to wheel chair. The provider had a policy to always use foot pedals with wheelchairs for safety, but had also been pushing person-centered practices to support people they serve to have more control of daily decisions. \r\n\r\nThe general practice for wheel chair use conflicted with the agency\u2019s practice.","Multiple_Choice__117":"0","Multiple_Choice__119":"0","Multiple_Choice__121":"0","Multiple_Choice__123":"2","Free_Text__124":"Team conversations about how this person wanted to live did not have consistency with the person\u2019s plan and guidelines related to wheelchair use. There was a practice of the home not to use foot pedals and given the numerous tasks in the morning, staff could not account for everything.","Multiple_Choice__125":"0","Yes_or_No__432":"Yes"}