Resident Restrained by Wheelchair Locks Without Medical Necessity
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and significant physical limitations was placed in a low Broda chair with the rear wheel locks engaged, preventing the resident from self-propelling the chair. The resident, who has diagnoses including progressive supranuclear ophthalmoplegia, dementia, and chronic respiratory failure, was observed on multiple occasions attempting to move away from the table and self-propel, but was unable to do so due to the engaged wheel locks. The resident was unable to reach or disengage the wheel locks independently. Staff members, including a Certified Nursing Assistant (CNA) and the Activities Director (AD), were observed engaging the wheel locks while the resident was at the dining table or after being assisted around the facility. The locks were only disengaged by staff when the resident needed to move, at which point the resident immediately began to self-propel. Interviews with staff confirmed that the wheel locks could act as a restraint and that the resident could not remove them independently. The facility's policy defines a physical restraint as any device that the resident cannot remove easily and that restricts freedom of movement. Staff interviews further confirmed that wheel locks should only be used during transfers and that engaging them at other times, especially when the resident cannot remove them, constitutes a restraint. The care plan indicated the resident was able to self-propel, but the use of wheel locks in this manner restricted the resident's movement without a documented medical need.