Wheelchair Provided Without Functional Brake
Penalty
Summary
A deficiency was identified when a resident with multiple medical conditions, including bilateral below-the-knee amputations, diabetes, peripheral vascular disease, COPD, dementia, and muscle weakness, was observed using a wheelchair that was missing a right-side brake. The resident, who was cognitively intact and able to self-transfer and operate his wheelchair, reported dissatisfaction with the wheelchair provided by the Therapy department, specifically noting the absence of the right brake. The missing brake prevented the resident from using public transportation, as the bus driver deemed the wheelchair unsafe. The resident was unsure how long the brake had been missing. Interviews with therapy staff revealed uncertainty regarding the status of the wheelchair's repair, with one therapist indicating a work order may have been placed, but the Therapy Manager was not aware of the missing brake until the issue was brought to her attention. The resident's care plan identified an increased risk for falls and included interventions related to wheelchair safety, but there was no clear process in place for inspecting wheelchairs to ensure they were in safe working order. The DON and Administrator confirmed that while the Therapy department provided wheelchairs, they were unsure who was responsible for their inspection and maintenance.