Failure to Include Wheelchair Seat Buckle Use in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for one resident who was observed using a seat buckle in her wheelchair. The care plan did not include a focus area or interventions for monitoring the use of the seat buckle, nor did it define specific interventions related to its use. Staff utilized the seat buckle, but the care plan lacked documentation and guidance regarding this device. This omission was confirmed by a clinical specialist, who agreed that the lap strap should have been added to the care plan. The resident involved was nonverbal, rarely or never understood, and unable to participate in cognitive assessments. She was totally dependent on staff for all activities of daily living, had significant upper and lower extremity impairments, and used a wheelchair for mobility. Her diagnoses included diabetes mellitus, aphasia, seizure disorder, malnutrition, and Rett's Syndrome, which contributed to severe muscle movement disability and loss of purposeful hand skills. Despite her complex needs and the use of a seat buckle, the care plan did not address this intervention, contrary to facility policy requiring comprehensive, person-centered care plans.