In an abbreviated survey performed in December 2011, Marquette County Medical Care Facility was cited for failing to report possible abuse and neglect of a resident. On October 13, 2011, a resident was found by staff on the floor with a fracture of his leg. Although the fall was unwitnessed and the resident could not explain what happened (due to his dementia), the director of nursing unilaterally determined that she could rule out abuse and neglect and did not report it to the state. The law requires, however, that nursing homes ensure that all alleged violation involving mistreatment, neglect, or abuse, including injuries of unknown source, are reported immediately to the state.
In that same survey, the facility was also cited for failing to put foot pedals on a resident’s wheelchair during an outing. As a result, when the resident’s feet dropped while being pushed in her wheelchair, she fell forward out of her wheelchair and landed face first on the ground. She suffered multiple nasal fractures, cuts, and injuries to her left eye when she fell.
The aide who was pushing the resident admitted that she did not offer to put the foot pedals on, nor did she explain to the resident the risk of not using the foot pedals. This aide also admitted that she should have put the resident’s foot pedals on, and that this would’ve taken just a “few extra minutes.”
The resident’s physical therapist also admitted that the aide should have put the resident’s foot pedals on the wheelchair for her safety because “you can never be 100% sure the residents will not just drop their feet.”
An activities aide told the state that the staff “never” bring the resident’s foot pedals on outings.
The resident’s foot pedals were found underneath a whole bunch of clothing in her closet.
At the time of this incident, the facility did not have a policy that addressed the use of foot pedals on wheelchairs during outings.