Failure to Maintain Sanitary and Safe Wheelchairs
Penalty
Summary
The facility failed to maintain wheelchairs in a sanitary, comfortable, and well-maintained condition, as evidenced by observations and interviews during a complaint survey. One resident attended a medical appointment in a wheelchair with a cushion that was found to contain urine and fecal matter, emitting a strong odor that had been a source of complaints for months. Upon inspection, the gel pad and pillow cover were visibly soiled, and the family, as well as medical staff at the appointment, were disturbed by the condition. Housekeeping staff confirmed that prior to this incident, there was no established schedule for cleaning or maintaining wheelchairs or their cushions, and the wheelchair in question appeared to have never been cleaned. Further observations revealed multiple wheelchairs across two nursing units in disrepair, including cracked and ripped vinyl on armrests, missing armrests, and exposed foam. Several residents were observed using these damaged wheelchairs, which lacked proper padding and support. The Nursing Home Administrator was made aware of these issues by both staff and family members, confirming the lack of a maintenance process for wheelchairs prior to the incident.