Failure to Maintain Safe and Properly Fitted Wheelchair Cushion
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and well-maintained wheelchair for a resident who was independently mobile via wheelchair. During observation, the resident’s wheelchair was noted to have tears on the back, a seat cushion that was smaller than the full depth of the seat, exposed metal rods on both sides at the front of the seat structure, and exposed screws bilaterally. Photographic evidence of these conditions was obtained. At the time of one observation, the resident was in bed with eyes closed while the deficient wheelchair condition was present. In an interview, the resident reported that a therapist had placed a cushion on the wheelchair because he was not comfortable, but the cushion was too small and caused leg pain because he could feel the metal against his thighs. Review of the care plan showed the resident was independent with wheelchair positioning, though he sometimes did not position himself appropriately. Occupational therapy documentation indicated services had been provided previously, with discharge notes stating the wheelchair had been fitted with a cushion and that the resident had achieved a goal of no discomfort for more than two hours. In a subsequent interview, the OT acknowledged that when the cushion was replaced, an appropriately sized cushion matching the approximately 18-inch seat depth was not available and confirmed that the cushion in use was not the proper size for the wheelchair.
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