Failure to Ensure Resident Freedom from Unnecessary Physical Restraints
Penalty
Summary
A deficiency occurred when a resident was not allowed to use her personal wheelchair, despite her expressed desire and ability to self-propel using her arms. The resident, who is unable to stand or use her lower limbs, reported that she had previously been mobile in her wheelchair before admission to the facility. Instead, she was provided with a Broda chair, which she could not move independently due to her inability to use her feet. Both the resident and her spouse questioned the restriction, as the resident was capable of upper body mobility. Review of the resident's medical records showed conflicting physician orders regarding her mobility and use of a wheelchair. Occupational therapy documentation indicated that the resident attempted to use a standard wheelchair but slid out of it, leading to recommendations for continued use of the Broda chair for safety. However, the Broda chair provided did not allow for independent movement, and the resident remained dependent on staff for mobility. The therapy team identified the need for a Broda chair with larger wheels that the resident could propel with her arms, and a requisition for this equipment was submitted, but not promptly authorized. The delay in obtaining appropriate seating equipment resulted in the resident being unnecessarily restricted in her movement for an extended period. The resident remained either in bed or in a Broda chair she could not move, despite her stated goal and ability to self-propel with her arms. The lack of timely action to provide suitable mobility equipment led to the use of a device that unnecessarily limited the resident's freedom of movement.