Resident Restrained by Locked Wheelchair
Penalty
Summary
A deficiency was identified when a resident with hemiplegia and hemiparesis following a cerebral infarction was found to be restrained by having their wheelchair locked, preventing independent mobility. The resident's left hand was contracted and the right hand was nonfunctional, making it impossible for the resident to unlock the wheelchair brakes independently. During an observation, the resident requested assistance to unlock the wheelchair so they could move closer to the dining table and propel themselves with their feet. Staff confirmed that the resident depended on them to lock and unlock the wheelchair, and the resident reported that staff locked the wheelchair from the back too often, restricting their movement. A review of the facility's restraint management policy indicated that physical restraints should not be used for discipline or convenience and only for medical treatment. However, the resident's inability to unlock the wheelchair brakes was not assessed during a prior evaluation for a specialized wheelchair, and staff practice did not align with the policy. Staff interviews confirmed that the wheelchair should only be locked during transfers, but in practice, it was being locked at other times, resulting in the resident being restrained and unable to move freely.