Failure to Ensure Proper Wheelchair Positioning and Support
Penalty
Summary
Facility staff failed to ensure proper wheelchair positioning and support for a resident with severe cognitive impairment who was dependent on staff for all activities of daily living and receiving hospice care. Despite physician orders for a tilt-in-space wheelchair with leg rests, repeated observations showed the resident seated without leg rests, resulting in unsupported, dangling legs. The headrest was consistently positioned against the resident's upper shoulders or back, leaving the head unsupported. Even when leg rests were attached, they were too short for the resident's long legs, causing the knees to be elevated and not in contact with the wheelchair seat. The headrest repeatedly failed to stay in position to support the head, and staff did not consistently attempt to reposition it or the resident's legs when they became unsupported. The unit manager confirmed that the facility had not contacted the hospice agency to reevaluate the wheelchair, as it was provided by hospice and selected based on height and weight. Staff interviews and observations indicated a lack of ongoing assessment and adjustment of the wheelchair and its components to ensure proper support and positioning for the resident, despite clear orders and the resident's total dependence on staff for mobility and positioning.