Failure to Maintain Safe Wheelchair Equipment
Penalty
Summary
The facility failed to maintain resident wheelchairs in a safe and functional condition, as evidenced by multiple observations of wheelchairs with ripped, peeling, or missing arm rest coverings and exposed foam or padding. Four residents, all with significant cognitive impairments and dependent on wheelchairs for mobility and staff for care, were affected. Specific observations included wheelchairs with foam sticking out, torn or cracked arm rests, and missing padding. These deficiencies were directly observed during routine checks and were not isolated incidents. Interviews with staff revealed that maintenance requests were communicated via forms or a clipboard at the nurses' station, but completion of repairs depended on the availability of the single maintenance staff member. The Maintenance Director was unaware of the need for repairs to the wheelchair arm rests, and there was no facility policy provided regarding the maintenance of wheelchair equipment. The Administrator confirmed that maintenance is informed of work orders through a communication binder and expected wheelchairs to be in good working order.