Inadequate Adaptive Equipment for Resident Mobility
Penalty
Summary
The facility failed to provide safe and comfortable adaptive equipment to maintain a resident's ability to perform activities of daily living, specifically mobility. Resident R34, who is cognitively intact but dependent on staff for transfers, reported not receiving the necessary assistance for mobility needs. Observations revealed that the resident's manual wheelchair was not suitable for safe transfers, as it lacked an adjustable back, making it difficult for staff to position the resident properly and safely. Interviews with nursing staff confirmed the challenges they faced in transferring the resident due to the inadequate wheelchair, which posed safety concerns. The physical therapist acknowledged that a wheelchair with a reclining back was an option but was unaware of the issues faced by the nursing staff, as there had been no observations of transfer attempts since August 2024. The director of nursing confirmed the lack of appropriate adaptive equipment, which hindered the staff's ability to safely transfer the resident as per the care plan.
Plan Of Correction
The facility immediately made available to resident R34 a reclining manual wheelchair. The facility has re-educated nursing staff on safe mechanical lift and transfers. The facility will compile a list of residents that need assistance with mobility (transfer and ambulation) and complete an audit to identify that the respective residents have the appropriate, safe and comfortable adaptive equipment for mobility. The facility will monitor residents that need assistance with mobility (transfer and ambulation) to review that resident's adaptive mobility equipment remains appropriate at least quarterly at each care conference or as needed. The facility will monitor nursing staff training and competency on safe mechanical lift and transfers upon hire and at least yearly thereafter, or as needed. Director of Rehabilitative Therapy / designee will audit residents' adaptive mobility equipment for each scheduled resident's quarterly / annual review, semi-weekly x3 months. Nurse Educator / designee will audit all current nursing staff and new nursing staff's education files for safe mechanical lift and transfers training and competency, monthly x3 months. Findings will be reported to the QAPI committee.