Failure to Provide Resident with Custom-Made Wheelchair for Transport
Penalty
Summary
The facility failed to ensure that a custom-made wheelchair was available and provided for a resident with a leg amputation during transport to a medical appointment. Staff statements and interviews revealed that the resident, who typically used a geri chair or remained in bed, was transferred to a standard wheelchair for an appointment, during which the resident began sliding out of the chair. Multiple staff members intervened to reposition the resident and eventually transferred the resident to a high-back wheelchair with a pillow for support. The resident did not report pain or injury during the incident. Further investigation revealed that the resident's custom-made wheelchair, provided by the VA and specifically fitted to accommodate the resident's needs following a leg amputation, had been lost by the facility on more than one occasion. The resident's daughter reported that the resident was repeatedly placed in other residents' wheelchairs for appointments, and that complaints about the missing wheelchair had been made to various staff and administrators. The facility's NHA confirmed that the custom wheelchair could not be located and acknowledged that there was no follow-up by staff to ensure the resident had access to the appropriate equipment.