Failure to Assess Resident for Safe Use of Electric Recliner
Penalty
Summary
The facility failed to comprehensively assess a resident with moderate cognitive impairment and multiple medical diagnoses, including dementia, anxiety, and limited mobility, for safe use of an electric recliner. The resident's care plan indicated the use of a recliner to elevate her legs and identified her as a fall risk requiring assistance for bed mobility and transfers. However, the physical device assessment did not include the electric recliner, and there was no documentation that the resident's ability to safely use the recliner had been evaluated. Observations showed the resident using the electric recliner independently, with the remote consistently within reach. During one incident, staff had to intervene when the resident elevated the recliner to a point where she nearly slid to the floor. Interviews with staff revealed inconsistent understanding of the resident's ability to operate the recliner remote, with some stating she could use it and others noting confusion and fidgeting. Nursing leadership confirmed the recliner should have been assessed as part of the physical device assessment and acknowledged this was not done. The facility was unable to provide policies related to assistive device and physical device assessments.