Failure to Safeguard and Inventory Resident-Owned Wheelchair Resulting in Loss
Penalty
Summary
The facility failed to protect a resident’s personal property and maintain an accurate inventory of belongings, resulting in the loss of the resident’s wheelchair. The resident, who had diagnoses including morbid obesity, muscle weakness, and chronic pain syndrome, was cognitively intact and used a manual wheelchair for mobility, with impaired range of motion in both lower extremities. Social services documentation showed that the resident was evaluated by a wheelchair company for a special wheelchair and that the new wheelchair was delivered to the resident, with the facility’s social service designee signing the delivery ticket. The wheelchair was paid for by the resident’s health insurance and was owned by the resident. However, the wheelchair was never added to the resident’s clothing and possessions list, despite facility policy requiring that personal belongings be inventoried upon admission and as items are replenished. When the resident was transferred to a general acute hospital and later admitted to another facility, the resident’s wheelchair was not returned. During interviews, the director of rehabilitation confirmed that the resident was wheelchair-bound, that the wheelchair was specifically fitted for the resident, and that it belonged to the resident for her own use and to take upon discharge. The administrator stated he did not know what happened to the wheelchair, acknowledged there was no invoice available, and confirmed the wheelchair was not added to the resident’s belongings list. A customer service representative from the wheelchair company confirmed that the resident’s health insurance paid for the wheelchair, that it was delivered to the facility, that the resident owned it, and that the facility was responsible for replacing the lost wheelchair. These failures resulted in the resident’s wheelchair being lost and the resident not having a wheelchair for mobility.
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