Failure to Maintain Wheelchair in Good Repair for Resident
Penalty
Summary
The facility failed to maintain a resident's wheelchair in good repair, resulting in a torn, ripped, and cracked vinyl cover on the left armrest. The resident, who had moderate cognitive impairment and relied on a wheelchair as her primary mobility device, was observed on multiple occasions with her left arm in contact with the damaged armrest. The resident reported that the damaged armrest irritated her skin at times and expressed a desire for it to be fixed. Weekly skin assessments indicated her skin was intact during the review period, and staff confirmed there was no redness or open areas at the time of observation. Despite the visible damage, nursing and aide staff either did not notice the issue or, when it was noticed, did not ensure the repair was reported and addressed. The nurse aide stated she had reported the issue to rehabilitation staff weeks prior, but the rehabilitation director denied receiving any such report. The maintenance department, responsible for repairs, was not made aware of the problem and did not conduct routine checks for wheelchair repair needs, instead relying on staff to submit work orders. Facility leadership, including the DON and Administrator, expected staff to be attentive to residents' mobility devices and to report repair needs promptly, but this did not occur in this instance.