Failure to Provide Resident with Prescribed Specialty Wheelchair and Cushion
Penalty
Summary
The facility failed to ensure the availability and working order of a personal tilt and space wheelchair with a specialized ROHO cushion for a resident with a history of pressure ulcers and specific seating needs. Occupational therapy documentation over multiple periods indicated that the resident was unable to use their prescribed wheelchair due to it being in disrepair and missing the required cushion. Despite repeated assessments and recommendations from occupational therapy and wound care staff for the use of a tilt and space wheelchair with a pressure-relieving cushion, the resident continued to be observed sitting in a standard high back wheelchair, while the prescribed wheelchair was found stored away and not in use. Interviews with therapy and wound care staff revealed that the resident's specialized wheelchair was not returned after a hospice discharge, and efforts to locate or replace the equipment were not made by facility management. The occupational therapist reported making multiple requests to the former therapy manager regarding the wheelchair, but these were not addressed. Additionally, the facility was unable to provide a policy regarding accommodation of needs when requested by surveyors during the survey period.