Failure to Maintain Resident's Tilt-in-Space Wheelchair per Manufacturer Guidelines
Penalty
Summary
The facility failed to obtain and maintain the manufacturer's guidelines for a Tilt-in-space wheelchair used by a resident with cognitive communication deficit, Alzheimer's disease, and legal blindness. The resident required maximum assistance for activities such as toileting hygiene, showering, and dressing, and used a personal Tilt-in-space wheelchair. During interviews, both the Director of Rehabilitation and the Maintenance Supervisor confirmed they did not have the user manual for the wheelchair because it was owned by the resident. The Maintenance Supervisor acknowledged that although adjustments had been made to the wheelchair in the past to ensure it was working, the absence of the manufacturer's manual meant they could not be certain that all necessary maintenance and safety checks were performed according to the manufacturer's recommendations. The facility's policy required maintenance personnel to follow the manufacturer's recommended maintenance schedule for all equipment, but this was not done for the resident's wheelchair.