Failure to Maintain Wheelchairs and Ensure Hazard-Free Equipment
Penalty
Summary
The facility failed to ensure that assistive devices, specifically wheelchairs, were properly maintained and free of hazards for three residents reviewed for essential equipment. Observations revealed that each of these residents was using a wheelchair with a cracked right armrest and exposed foam while seated in the dining room. All three residents had care plans that included wheelchair mobility, and their medical histories included conditions such as dementia, cerebral vascular accident, heart failure, hypertension, weakness, and unsteadiness. At the time of observation, none of the residents had skin problems or tears on their arms. Interviews with staff indicated that the process for reporting wheelchair repairs was inconsistent. CNAs typically reported needed repairs verbally to the nurse in charge, while RNs stated that staff were supposed to inform the maintenance department. The Maintenance Director explained that repairs should be entered into the electronic maintenance system, but acknowledged that staff often failed to do so, making it difficult to track and address needed repairs. A review of the electronic maintenance system showed no entries for wheelchair armrest repairs during the relevant period, and the Administrator confirmed that there was no policy or procedure in place for equipment repair at the facility.