Failure to Provide Recommended Rehabilitative Services and Equipment
Penalty
Summary
The facility failed to implement recommended specialized rehabilitative services for a resident who had a history of muscle wasting, heart disease, osteoarthritis, unsteadiness, and postural kyphosis. After the resident sustained a fall from their wheelchair, a physician ordered a physical therapy evaluation and treatment. The physical therapy evaluation identified the need for a possible tilt chair to decrease the resident's fall risk, following a noted decline and the resident's report of sliding out of the wheelchair due to a bed pad. Despite this recommendation, there was no evidence that a tilt chair was trialed or that further action was taken to address the resident's wheelchair needs. The resident, who was cognitively intact and required assistance from at least two staff for bed mobility and transfers, reported ongoing issues with the condition of their wheelchair and stated that therapy staff were supposed to be working on obtaining a new wheelchair. Observation confirmed the wheelchair was in poor condition, with missing material and tape applied by the resident. The Therapy Director verified that although therapy staff had planned to trial a different wheelchair, there was no documentation or evidence that this was ever initiated or completed.