Failure to Maintain and Monitor Wheelchair Seat Belt for Resident
Penalty
Summary
A deficiency was identified when a resident who required a seat belt in his wheelchair was observed multiple times with a seat belt that was slack, improperly positioned, and frayed nearly in half due to rubbing against a sharp edge of the wheelchair frame. Despite repeated observations over several days, the seat belt remained in poor condition and was not replaced or repaired. The resident, who had diagnoses including cerebral palsy, shaken infant syndrome, and intellectual disabilities, was able to unbuckle the seat belt but could not re-buckle it independently. Staff, including the Social Service Director and Maintenance Staff, acknowledged the poor condition of the belt during observations. Review of the resident's medical record showed an initial adaptive device review and a physician's order for a wheelchair with a seat belt, but neither specified the type of belt or included parameters for ongoing assessment of its placement, appropriateness, or condition. The care plan also lacked details regarding the type of belt and did not address ongoing monitoring or assessment. Facility policy required quarterly review of adaptive devices by the IDT team and inclusion of device use in the care plan, but these requirements were not met for this resident.