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F0600
G

Residents Subjected to Forced Removal from Power Wheelchairs and Loss of Mobility Rights

Santa Monica, California Survey Completed on 09-04-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect two residents from mental and physical abuse when unidentified corporate staff forcefully removed them from their motorized power wheelchairs (MPWC) and placed them into manual wheelchairs (MWC) against their wishes and without clinical justification or consent. The incident involved multiple staff members, including corporate representatives, who attempted to physically transfer the residents despite their verbal refusals and distress. The residents were not provided with an opportunity to speak with law enforcement when the police were called, and their autonomy and right to make decisions regarding their mobility devices were disregarded. One resident, with a history of multiple medical conditions including cellulitis, pressure injuries, chronic pain, and dependence on a wheelchair, was subjected to forceful attempts to remove her from her MPWC. She repeatedly expressed her desire to keep her MPWC and asked to speak with familiar staff or her physician, but was ignored. During the incident, several staff members physically attempted to remove her from the chair, causing her emotional distress and pain in her left arm and shoulder. She was left in a manual wheelchair and confined to bed for an extended period, resulting in psychosocial harm such as anxiety, helplessness, and emotional distress. She was later transferred to a hospital for evaluation of shoulder pain. Another resident, diagnosed with multiple sclerosis, Parkinson's disease, and other conditions leading to dependence on a wheelchair, was also removed from her MPWC by a group of unfamiliar staff. She was transferred to bed using a Hoyer lift and left without her preferred mobility device for several days, which led to her remaining in bed, crying, and experiencing a loss of independence. Both residents' care plans indicated their dependence on MPWCs for mobility and participation in activities, yet these were disregarded by the staff involved. The actions taken by the facility staff resulted in both residents experiencing a loss of autonomy, dignity, and independence, as well as significant psychosocial harm.

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