Failure to Maintain Functional Wheelchair Brakes for Resident with Severe Impairment
Penalty
Summary
The facility failed to provide a safe and functional wheelchair for a resident with dementia and severe cognitive impairment, who required substantial assistance with transfers and was dependent for toileting and bathing. The resident's wheelchair had a malfunctioning left brake that could not lock the wheel securely, as observed by staff and confirmed during interviews. The issue was known to some staff members, including a CNA who reported the problem to the maintenance supervisor and assistant, but there was no documentation of a maintenance request or repair for the wheelchair in the facility's maintenance log for the past three months. Despite the resident using the wheelchair daily for activities and transfers, the malfunctioning brake was not addressed or communicated effectively to the maintenance team or the Director of Nursing. Multiple staff members, including the restorative nursing assistant and CNA, acknowledged the brake issue and its potential to cause harm, but the maintenance staff and DON were unaware of the problem until the day of the survey. The facility's policy required that assistive devices be maintained and repaired as needed, but this was not followed in the case of the resident's wheelchair.