Failure to Maintain Safe Wheelchair Armrests
Penalty
Summary
The facility failed to maintain wheelchair armrests in safe and functional condition for three residents with significant mobility and cognitive impairments. Observations revealed that one resident's wheelchair had a missing vinyl covering on the left armrest, exposing interior stuffing, and the right armrest was loosely attached with tape and missing most of its cushion material. Another resident's wheelchair had a split armrest with cushion material hanging down, and a third resident's wheelchair had both armrests cracked with sharp edges exposed. All three residents were observed using these wheelchairs during daily activities, and two expressed a desire for new armrests, though neither reported having skin injuries at the time. Interviews with staff indicated inconsistent practices regarding the reporting and repair of wheelchair deficiencies. Certified Nursing Assistants (CNAs) were expected to report needed repairs through an electronic maintenance system, but at least one CNA admitted to never using the system for wheelchair issues. The Director of Rehab stated that her department repaired armrests when they noticed damage, regardless of whether residents were currently receiving rehab services. The Maintenance Supervisor indicated that while he performed repairs, the Rehab Department generally handled most wheelchair maintenance. The facility's policy required all equipment to be maintained in good working order to ensure resident safety, but these procedures were not consistently followed, resulting in unsafe wheelchair conditions.