Failure to Maintain Safe Wheelchair Equipment and Provide Adequate Linens
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for residents, specifically those dependent on wheelchairs and those requiring adequate linens for personal care. Two residents who relied on wheelchairs experienced issues with the condition and maintenance of their mobility devices. One resident's wheelchair had both armrests torn and missing all cushioning, causing discomfort, while another resident's personalized mechanical wheelchair had a broken armrest that had not been repaired for approximately two weeks after being damaged during a transfer. Staff, including nurses and therapists, were aware of these issues, but repairs were delayed or not initiated due to uncertainty about insurance coverage and lack of communication among staff and management. Additionally, the facility failed to provide adequate clean linens for resident care. On a specific day, staff reported a lack of clean towels and facecloths, resulting in postponed or interrupted personal hygiene care, such as bed baths and incontinence care. Staff described having to divide limited clean linens among residents and confirmed that some residents did not receive timely or sufficient care due to the shortage. The facility had discontinued the use of disposable premoistened cleansing cloths, relying instead on washable cloths and dry disposable wipes, which staff and residents described as inadequate for effective care, especially for those with fragile skin or wounds. Multiple staff interviews confirmed that the lack of clean linens and limited availability of mechanical lifts led to delays in resident care, including bathing, transfers, and incontinence care. Residents and their families reported dissatisfaction with the quality and timeliness of care, citing postponed assistance and the need to supply their own cleansing cloths. The facility's housekeeping supervisor attributed the linen shortage to miscommunication regarding staff scheduling, and there was confusion among staff about the location of clean linen storage, further contributing to the deficiency.