Failure to Ensure Wheelchair Safety and Timely Equipment Assessment
Penalty
Summary
Facility staff failed to ensure the safety of a resident's wheelchair, resulting in multiple falls for the resident. The resident reported that the brake lever on their wheelchair was broken, which was confirmed by a surveyor's assessment showing that the right brake lever did not fully lock the wheel, allowing movement. The left brake lever functioned properly. The resident experienced several falls on documented dates while attempting to stand up or sit down using the wheelchair. Additionally, another unoccupied wheelchair in the facility was found to have a similar issue with its right brake lever. There were no visible indicators, such as tickets or signs, to show that the wheelchairs required repair. Interviews with staff revealed that nursing staff are responsible for reporting equipment concerns, which are then submitted as work orders through a designated system. However, the maintenance technician does not proactively check equipment and only addresses issues based on submitted reports. The Director of Nursing was unable to provide documentation that the resident's personal wheelchair had been assessed for safety hazards upon admission or prior to use in the facility.