Deficient Wheelchair Maintenance for Resident
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition for a resident, identified as R761. The resident, who was admitted to the facility with diagnoses including high blood pressure, diabetes, and absence of both lower legs, was using a manual wheelchair as indicated in their Minimum Data Set. Physician orders specified that the resident should be out of bed in a manual wheelchair equipped with a pressure reduction cushion, bilateral leg rests, and an anti-rollback safety device to reduce fall risk. However, during an interview, the resident expressed concern about the wheelchair's brakes not working, fearing a fall during transfers. An observation confirmed that the wheelchair's bilateral braking mechanisms were loose, had yellow tape around the handles, and were not functioning properly, allowing the resident to move the wheelchair forward even when the brakes were engaged. A Licensed Practical Nurse (LPN) acknowledged the issue, stating they believed the brakes had been fixed and indicated they would contact the therapy department to address the problem. This deficiency highlights the facility's failure to ensure the resident's wheelchair was maintained in a safe operating condition, as required by regulations.
Plan Of Correction
1. Resident R761 wheel chair was adjusted to residents' preference and safety. 2. The therapy and maintenance team audited resident wheel chairs to ensure they operated to residents' safety. 3. The Therapy team and Maintenance team were re in serviced to ensure mechanical patient care equipment is in safe working order. 4. The therapy team will audit daily for two weeks to ensure mechanical patient care equipment is in safe working order. Audit findings will be shared by QAPI committee.