Failure to Maintain Wheelchairs in Good Repair for Multiple Residents
Penalty
Summary
The facility failed to maintain wheelchairs in good repair for three out of four residents observed, resulting in wheelchair armrests and backs that were missing, torn, or tattered. Observations during the initial tour revealed that one resident's wheelchair had a tattered and torn right armrest and back cover, with the back cushion cover not connected and missing a screw. Two additional wheelchairs, found in the hallway near resident rooms, were observed to have discolored tape, missing armrests, and tattered or torn back cushions and armrests. These deficiencies were confirmed by staff, including an LPN and a CNA, who acknowledged that the damaged areas could potentially cause skin tears. Record reviews indicated that the affected residents had diagnoses such as difficulty in walking, neuropathy, peripheral vascular disease, radiculopathy, arthritis, and type 2 diabetes. Their care plans identified them as being at risk for skin impairment, skin breakdown, and skin tears due to their medical conditions and fragile skin. Each resident's care plan also documented the use of a wheelchair as special equipment, further emphasizing the importance of properly maintained mobility devices. Interviews with staff revealed inconsistencies in the facility's equipment inspection and maintenance practices. The Director of Nursing stated that wheelchairs were checked before each use and that CNAs were responsible for notifying maintenance of any issues. However, the Maintenance Assistant/Floor Technician later admitted that the documentation of monthly wheelchair inspections was incorrect, despite records indicating that inspections had been marked as completed. The observed deficiencies in wheelchair condition were not identified or addressed through the facility's documented inspection process.