Failure to Maintain Resident Wheelchair in Clean and Sanitary Condition
Penalty
Summary
The facility failed to ensure that necessary equipment, specifically a resident’s wheelchair, was maintained in a clean and sanitary condition. Over multiple days of observation, the wheelchair assigned to a resident with severe cognitive impairment and limited mobility was found to have visible dirt, white and brown flakes, and crumbs caked on the seat cushion and frame. The resident, who had diagnoses including hypertensive heart disease, vascular dementia, and acute kidney failure, reported that the wheelchair had been dirty for a long time. Staff interviews confirmed that it was the responsibility of night shift CNAs to check and clean wheelchairs, but the resident’s wheelchair remained unclean over several days. Further review revealed that the facility did not have any policies or in-service training related to environmental or wheelchair cleaning. Multiple staff members, including CNAs, LPNs, and the DON, acknowledged that cleaning wheelchairs was part of the night shift CNAs’ duties, but the lack of a formal policy or training contributed to the ongoing issue. The deficiency was identified through direct observation, resident and staff interviews, and review of facility records.