F0604

D

Improper Use of Reclining Wheelchair as Undocumented Restraint

Salisbury, North Carolina Survey Completed on 01-02-2026

Penalty

Fine: $20,385

Summary

The deficiency involves the facility’s failure to identify and manage a reclining Broda wheelchair as a physical restraint when used in a manner that restricted a resident’s ability to rise independently, and without medical justification or required documentation. The resident involved had emphysema, a history of cerebral infarction, repeated falls, and cognitive impairment, being oriented to person only and confused. On readmission, the Nursing Re-admission Assessment Tool completed by a nurse included sections for Device Assessment and Restraint Identification, but these sections were left blank. The resident’s EMR contained no physician orders for any device that would restrict movement and no documentation of identification, assessment, or use of a restraint.

Surveyors observed the resident on multiple occasions seated in a reclining Broda wheelchair at varying back angles, including approximately 110 degrees and 130 degrees. At several observations when the chair was reclined to about 130 degrees, the resident appeared to be attempting to sit up or stand by pulling her upper body forward, including while near the nursing station, in a hallway, and in her room. At other times, when the chair was reclined to about 110 degrees, the resident appeared comfortable, content, and able to feed herself or participate in activities. During therapy, the same chair was observed in an upright position while the resident engaged in therapeutic exercise.

Interviews with staff revealed that the chair was intentionally reclined to prevent falls rather than for a documented medical treatment purpose. Two NAs stated that the chair was reclined that far because the resident was at high risk for falls and agreed that the recline was intended to prevent her from falling, noting it could be less reclined when someone was close by. A nurse reported that during a prior admission the resident used the same type of reclined wheelchair, that the resident had multiple falls, and that the resident could get out of the wheelchair when it was in a normal sitting position, which is how she fell. The Rehab Therapy Manager acknowledged that reclining the chair beyond approximately 110 degrees would make it a restraint and stated that the 130-degree position was not typically used except for rest. The DON stated she understood that a 130-degree recline would be considered a restraint and that the Broda chair was never to be used as a restraint. The Medical Director reported he was not aware of any medical symptoms that would warrant use of a 130-degree reclined wheelchair for this resident and did not recommend restricting or restraining the resident’s movements.