Failure to Ensure Functional Wheelchair Brakes for High Fall Risk Resident
Penalty
Summary
A deficiency was identified when a resident's wheelchair was found to have non-functional brakes on the left side, which had not been addressed for over a month despite the resident notifying multiple staff members. The resident, who had a history of falls, hemiplegia, hemiparesis, impaired balance, and was part of the facility's Fall Star program, reported the issue to staff including the Director of Rehabilitation (DOR) but the problem persisted. Observations confirmed that the left brake did not prevent the wheelchair from moving, and the brake mechanism appeared loose. Interviews with staff revealed that neither the Certified Nursing Assistant (CNA) nor the Registered Nurse (RN) assigned to the resident were aware of the brake issue. The CNA could not recall the last time the wheelchair was checked, and the RN stated that she had not been informed of the problem. The DOR acknowledged being told about the issue by the resident on the day of the survey and intended to refer it to Occupational Therapy (OT), but there was no documentation or evidence that the wheelchair had been assessed for functionality or safety in the preceding months. Further interviews with the Occupational Therapist (OT), Assistant Director of Nursing (ADON), and Administrator (ADM) indicated that there was no clear record of regular wheelchair safety checks or assessments for this resident. The facility's policy required therapy to evaluate wheelchair appropriateness and functionality, especially for residents identified as high fall risks. However, documentation and staff interviews confirmed that these evaluations had not been consistently performed, resulting in the resident using a wheelchair with faulty brakes for an extended period.