Deficiency in Wheelchair Positioning and Maintenance
Penalty
Summary
During a recertification survey, it was found that the facility failed to ensure proper positioning and equipment for a resident with limited range of motion in their lower extremities. The resident, who was independent in cognition and had a diagnosis that included decreased muscle strength, was observed multiple times with their foot dangling off the foot pedal of their wheelchair. Despite being evaluated for wheelchair mobility to increase strength for self-propelling, there was no documentation of an assessment for proper positioning or necessary repairs to the wheelchair. The occupational therapist noted that the wheelchair's phalange was not functioning correctly, causing the foot pedal to swing out and making it difficult for the resident to keep their foot in place. Additionally, the left foot box was out of position and required fixing. A certified nurse aide observed the issue but did not report it, and the occupational therapist confirmed that there was no official schedule for assessing wheelchairs or documented audits. This lack of communication and documentation contributed to the deficiency in providing necessary care and equipment for the resident.
Plan Of Correction
Plan of Correction: Approved March 21, 2025 F 688 Increase/Prevent Decrease in ROM/Mobility I. The Following Actions were accomplished for the residents identified in the Sample: - The wheelchair for Resident #36 was repaired first thing in the morning on (MONTH) 27, 2025. - Certified Nurse Aide #14 received an education on the importance of promptly reporting broken wheelchair to their immediate supervisor to ensure that repairs are initiated without delay. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: - All residents have the potential to be affected by this deficient practice. - The Director of Rehab/Designee will identify all residents utilizing bariatric wheelchairs. This will specifically focus on foot pedals that show signs of increased wear and tear resulting from the weight of the foot pedal support. - Any identified deviations will be promptly reported to the Support Services for immediate repair and provide appropriate intervention or change existing intervention. III. The following systemic changes will be implemented to ensure new interventions are added to the interdisciplinary care plans for continued compliance with regulations: - All Nursing Staff will be provided with an in-service education for promptly reporting any broken wheelchair to their immediate supervisor. This ensures that necessary repairs are initiated without delay, thereby maintaining resident’s functional status. - The Occupational Therapist will continue to monitor the foot pedals of residents using bariatric wheelchairs, as these experience increased wear and tear due to the extent of weight put on them. During quarterly screenings, the Occupational therapist will document assessment findings to ensure proper positioning in wheelchair and address necessary adjustments or interventions. IV. The facility’s corrective action will be monitored to ensure the deficient practice does not recur by utilizing the following Quality Assurance practices: - The Director of Rehab/Designee will develop an audit tool entitled “Bariatric Resident - Wheelchair Positioning.” This audit tool will be utilized to monitor residents who use bariatric wheelchairs focusing on foot pedals that exhibit wear and tear. It will help identify those requiring repairs or additional devices to maintain their functional mobility. Additionally, the tool will ensure that all necessary documentation regarding resident’s wheelchair positioning is reflected in the resident’s chair. The audit will be conducted weekly for three (3) months. - The Support Services Director/Designee will develop an audit tool entitled “Wheelchair Reporting and Repair.” This tool will be utilized to assess whether the staff have properly followed the facility’s procedure for reporting broken wheelchairs and to verify that repairs were completed in a timely manner. Responsible Person: The Administrator is responsible for ensuring all above is completed.