Failure to Provide Resident with Required Assistive Device
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and multiple diagnoses, including dementia, heart failure, and difficulty walking, did not have access to their prescribed assistive device, a walker. The resident's care plan indicated they were a fall risk with a history of two recent falls and required the use of a walker for safe ambulation. Observations on multiple occasions revealed the resident ambulating in their room without supervision or a walker, and the walker was not present in the room during these times. Further review and staff interviews confirmed that the walker had not been seen with the resident for at least a week, and staff were unsure of its location. The facility's policy required that assistive devices be provided, maintained, and accessible to residents based on their care plan and comprehensive assessment. Despite these requirements, the resident was left without the necessary assistive device, resulting in a failure to reasonably accommodate their needs and preferences.