Failure to Provide Ordered Electric Wheelchair and Medically Related Social Services
Penalty
Summary
The deficiency involves the facility’s failure to provide medically related social services, specifically an ordered electric wheelchair, to a paraplegic resident. The facility’s policy on Social Services, dated September 2021, stated that medically related social services are provided to maintain or improve each resident’s ability to meet everyday physical needs, including equipment for ambulation. Resident 1, originally admitted in November 2023 and later readmitted, had diagnoses including paraplegia and psychoactive substance abuse. A Minimum Data Set dated October 10, 2025, documented intact cognition and memory, with the resident requiring partial to total assistance for activities of daily living and being dependent for transfers and toileting. On July 14, 2025, the physician ordered an electric wheelchair for the resident and directed the facility’s case manager to request authorization. However, there was no documentation or endorsement of follow-up on this order. During an interdisciplinary care conference on September 26, 2025, attended by the resident’s family member, Social Services staff, the Director of Rehabilitation, and the Director of Staffing and Development, the team determined that providing an electric wheelchair was not appropriate at that time. Their rationale was the resident’s history of substance use disorder, prior fentanyl use, and recent contraband incidents involving marijuana vape products and non-prescribed supplements, and they believed access to an electric wheelchair could increase the potential for self-harm related to drug-seeking behavior. The record also noted that the resident was using a manual wheelchair with staff and family assistance and could navigate the facility and go on outings with support. Interviews and observations showed that the resident could not independently and safely propel the manual wheelchair. The resident’s family member reported that the resident had requested an electric wheelchair since July 2025 and had not received it, and that the resident was experiencing isolation and loneliness. During observation in the resident’s room, the resident stated he could not safely wheel himself alone and felt his mobility and right to move freely were restricted; when attempting to propel the manual wheelchair in a straight line, he veered to the right and struck the bedside table and wall. A physical therapist confirmed the resident could not propel a manual wheelchair due to poor coordination. The current case manager stated she was unaware of the electric wheelchair order and that there was no documentation regarding the request. The Social Services Director stated she believed Social Services only arranged DME for residents being discharged and did not know what happened to the July 2025 order, while the DON stated Social Services was responsible for arranging DME for custodial residents. The Administrator acknowledged that there was no documented follow-up on the July 14, 2025 electric wheelchair order until the September 26, 2025 meeting and that the decision not to provide the electric wheelchair was based on concerns about the resident’s safety related to illegal substance use behaviors.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.