Failure to Maintain Safe Wheelchair Equipment
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition, specifically regarding a loaner wheelchair provided to a resident admitted for rehabilitation following a hip replacement. The resident, who had a history of femur fracture, repeated falls, and unsteadiness, reported that the right brake on her wheelchair was broken and did not fully engage, causing the wheelchair to move slightly during transfers. The resident communicated this issue to therapy staff, who attempted to address it but lacked the necessary tools and subsequently reported it to the Director of Rehabilitation (DOR) the following day. Observation confirmed that the right-side brake did not provide complete braking function. Interviews with therapy staff and the DOR revealed that the facility did not have a specific policy for wheelchair maintenance and relied on the general facility maintenance policy. The DOR and therapy staff acknowledged the issue after it was reported and described the process for submitting maintenance requests. The facility's policy stated that all equipment should be maintained in good working order to ensure safety, but the lack of a specific wheelchair maintenance protocol contributed to the delay in addressing the malfunctioning brake.