Failure to Ensure Appropriate Wheelchair Assessment and Maintenance for Resident with Limited Mobility
Penalty
Summary
The facility failed to ensure that a resident with limited mobility received appropriate services and equipment to maintain or improve mobility with maximum practicable independence, unless a reduction in mobility was unavoidable. The resident in question had significant medical conditions, including morbid obesity, muscle weakness, and difficulty walking, and relied on a motorized wheelchair (MWC) for mobility. Despite documented weights consistently above 550 pounds, there was confusion and lack of verification regarding the wheelchair's weight capacity, with conflicting information from various sources and no clear documentation or assessment by facility staff to confirm the suitability of the equipment. Multiple interviews revealed that the resident experienced repeated mechanical issues with the MWC, including broken and bent casters, which led to reduced use of the wheelchair due to safety concerns. The facility staff, including the Director of Rehabilitation (DOR), Director of Nursing (DON), and Administrator (ADM), were aware of the equipment issues but did not take timely or coordinated action to assess the wheelchair's appropriateness or arrange for necessary repairs. The facility's therapy and nursing staff did not refer the resident for a wheelchair evaluation, and there was a lack of communication and follow-through regarding responsibility for repairs and equipment replacement, despite clear indications from the resident's insurance that the facility was responsible for durable medical equipment (DME) while the resident remained in the facility. Documentation and interviews further indicated that the facility did not obtain or review the wheelchair's specifications or owner's manual to verify its weight capacity, nor did they maintain records of repairs or ensure that the resident's needs were being met. The resident, feeling unsafe and unsupported, attempted to resolve the issues independently and through external vendors, but encountered barriers due to outstanding balances and vendor policies. The facility's failure to assess, document, and provide appropriate equipment and services resulted in the resident being at risk of unsafe mobility and not receiving care to maintain or improve range of motion and independence.