Failure to Remove Unsafe Wheelchair with Broken Brake
Penalty
Summary
A deficiency occurred when a resident with multiple medical diagnoses, including moderate cognitive impairment and a high risk for falls, was observed using a wheelchair with a broken right brake. The resident, who is dependent for transfers and uses the wheelchair as a primary mode of locomotion, reported the broken brake to the surveyor. Staff, including a CNA and the Maintenance Director, were either unaware of the issue or had not addressed it despite being informed. The Maintenance Director acknowledged being aware of the broken brake but had not inspected or repaired it, citing competing priorities. The Maintenance Assistant also did not check the maintenance log, and the Restorative Director attempted to remove the unsafe wheelchair but did not notify social services when the resident refused. Facility policy requires that malfunctioning equipment be immediately removed from use and reported for repair, and that social services be notified in cases of resident refusal. Despite these policies, the resident continued to use the unsafe wheelchair for at least two days, and the broken brake was not repaired or removed from service. Multiple staff members confirmed the wheelchair was unsafe and could lead to incidents, but the necessary steps to ensure resident safety were not taken in a timely manner.