Failure to Develop Comprehensive Care Plans for Residents Using Motorized Wheelchairs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents who used motorized wheelchairs, resulting in unmet needs and safety concerns. For one resident, the care plan did not specify whether she could leave the building for appointments using her motorized wheelchair, nor did it indicate if staff accompaniment was required or which staff should be responsible. Additionally, the care plan did not address the need for verbal cues for safety, as identified in the occupational therapy assessment, which stated the resident required close supervision and verbal cues when outside the facility. This lack of detailed planning contributed to an incident where the resident fell in the parking lot while using her motorized wheelchair outside the facility. For the second resident, the care plan only noted the use of an electric wheelchair for locomotion within the facility and did not document her preference for using the facility van for appointments or assess her safety when using the motorized wheelchair outside. The resident expressed discomfort and a sense of unsafety when using a borrowed van with a manual lift, but this was not reflected in her care plan. The facility's policy requires comprehensive care plans with measurable objectives and clear staff responsibilities, but these requirements were not met for either resident.