Failure to Provide Necessary Equipment for Resident Mobility
Penalty
Summary
The facility failed to provide a resident, identified as Resident 104, with the necessary care and services to perform activities of daily living, specifically by not providing an appropriate wheelchair for transfers and out-of-bed activities. Resident 104 was readmitted to the facility with diagnoses including muscle weakness and lack of coordination. Despite having the capacity to understand and make decisions, the resident was noted to have severe cognitive impairment and functional limitations in both upper and lower extremities, requiring dependent assistance for bed-to-chair transfers. The care plan for Resident 104 indicated a need for necessary equipment to improve functional abilities, yet no wheelchair was provided. Observations and interviews revealed that Resident 104 had been asking for a wheelchair since admission but had not received one, preventing participation in activities and going outside. The Director of Rehabilitation acknowledged the importance of providing proper equipment like a wheelchair to prevent muscle atrophy and promote environmental stimulation. However, the process of assessing and providing a wheelchair was delayed, with the Director admitting that the facility should have initiated this process upon the resident's admission. Further interviews with staff, including a CNA and LVN, highlighted a lack of encouragement for the resident to get out of bed, which is crucial for preventing health issues such as pneumonia. The Director of Nursing emphasized the importance of residents getting out of bed for mental and physical health benefits. It was also noted that the facility lacked a policy and procedure for providing wheelchairs and equipment, contributing to the deficiency in care for Resident 104.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/6/25 Resident 104 was provided with a wheelchair. On 3/6/25, the Director of Rehabilitation (DOR) offered Resident 104 to get out of bed with the provided wheelchair; however, Resident 104 refused to get out of bed. On 3/7/25, the DOR offered Resident 104 to get out of bed with the provided wheelchair; however, Resident 104 refused to get out of bed. On 3/21/25, Resident 104 was offered to get out of bed by the DOR; however, Resident 104 refused. How the facility will identify other residents, having the potential to be affected by the same deficient practice, and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/10/25, the DOR conducted an audit to ensure all residents who can have a wheelchair have a wheelchair. Wheelchair tags were provided for each resident to identify their wheelchair. No other residents were affected by this deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/11/25, the DOR in-serviced the Therapy Department on assessing and providing a resident with a wheelchair. The DOR/designee will evaluate new admissions and re-admissions on their functional ability to use a wheelchair. The DOR/designee will then provide the new admission or re-admission with the appropriate wheelchair. The Medical Records Director will audit daily for 5 days weekly for 2 weeks and monthly thereafter to ensure new admissions and re-admissions have been provided a wheelchair if applicable. How the facility plans to monitor its performance to make sure that solutions are maintained: The Director of Nursing will report to the Quality Assessment and Assurance committee during its monthly meeting the status of the compliance for providing residents with a wheelchair for three months or until compliance is met.