Improper Wheelchair Reclining and Positioning Leading to Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was safely positioned in a tilt‑in‑space wheelchair and not reclined beyond forty‑five degrees, which contributed to two falls. The resident had multiple psychiatric diagnoses, including catatonic disorder, major depressive disorder, anxiety disorder, delusional disorder, and unspecified psychosis, and had a BIMS score of 10/15 indicating some memory deficits. The admission assessment and care plan identified impaired balance, substantial assistance needs for bed mobility, and dependence on staff for transfers, with fall‑risk interventions such as encouraging time at the nurse’s station, scheduled toileting, and removal of the walker. On one occasion, nursing staff responded to a report of a fall and found the resident lying on the right side in the dining room with a 2 cm laceration to the right eyebrow. At that time, the resident’s wheelchair was found reclined so that the resident had been lying flat, and staff reported the chair had been reclined to prevent the resident from climbing out, although they could not identify who reclined it. The resident had been assisted back into the wheelchair by two staff, and the incident was documented, including notification of family, the DON, and the provider. On a subsequent occasion, the resident was again in a reclined position in a tall‑back custom wheelchair near the nurse’s station when the wheelchair tipped backwards and the resident slid out over the headrest. Staff reported that the resident had a history of leaning and lunging forward in the wheelchair and that they often reclined the wheelchair to an almost lying position to prevent the resident from getting out, to help the resident rest, and because staff could not always watch the resident. Therapy later identified that the tilt stop on the wheelchair was broken, allowing the chair to be fully reclined beyond forty‑five degrees, and the OT stated staff should never have used the reclining function to keep the resident in the chair and that reclining beyond forty‑five degrees was not safe. The DON reported being unaware that staff had been reclining the resident in this manner prior to the falls, and there was no facility policy on wheelchair positioning available for review.
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