Failure to Provide Appropriately Sized Wheelchair for Resident
Penalty
Summary
The facility failed to reasonably accommodate a resident’s needs and preferences by not providing a wheelchair appropriate for her size. The resident, admitted with diagnoses including edema, unspecified quadriplegia, acute pain, muscle spasm, central cord syndrome of the cervical spinal cord, and seizures, had intact cognition with a BIMS score of 15 and used a wheelchair for mobility. Her MDS and care plan documented limited physical mobility, bilateral upper and lower extremity impairments, and dependence on staff for transfers, toileting, and personal hygiene, as well as risk for pressure ulcers and the need to avoid striking extremities on hard surfaces. During observation, the resident was seen sitting in a wheelchair with no space between her hips and the sides of the chair, and she reported that the wheelchair was too small, rubbed against her hips, and that she had previously informed the administrator of this issue over a month earlier after gaining weight. Multiple CNAs confirmed that the resident had complained that her wheelchair was too small and was hurting her hips, and that they had notified the administrator and shown her that the wheelchair did not fit properly. Another staff member reported noticing that the resident’s wheelchair was too small and that the resident had edema at times and had gained weight. On a subsequent observation, three CNAs were seen transferring the resident from the wheelchair to bed via Hoyer lift, and redness and indentations were observed on both hips where they had been pressed against the sides of the wheelchair; an LPN confirmed these findings. Therapy staff stated that residents are screened every three months and as needed, but nursing had not notified therapy that this resident’s wheelchair was too small. The administrator acknowledged that a requisition for a larger wheelchair had been cancelled and confirmed that no other measures had been implemented to obtain an appropriately sized wheelchair for the resident.
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