Failure to Assess Resident Prior to Use of Broda Chair
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received an appropriate assessment before the use of a Broda chair, a specialized seating device. The facility could not provide a policy specific to assessment prior to use of mobility devices, and the existing Functional Impairment – Clinical Protocol only generally addressed assessment upon admission, with significant change, and periodically, including use of consultations and therapy evaluations to guide care planning. The resident involved had multiple diagnoses, including Down syndrome, unspecified cerebral palsy, type 2 diabetes mellitus, congestive heart failure, chronic atrial fibrillation, epilepsy, benign prostatic hyperplasia, chronic kidney disease stage 3, anxiety, restlessness and agitation, lumbar compression fractures, abdominal distension, obstructive uropathy, and urogenital implants. The most recent MDS showed severely impaired memory and cognitive skills for daily decision-making, but no impairment in upper or lower extremity function, use of a manual wheelchair for mobility, and no use of restraints, bed rails, bed alarms, or chairs that prevent rising. The care plan documented limited mobility with supervision for short ambulation distances and wheelchair use, and addressed fall risk and safety with interventions such as staff supervision and environmental safety measures. Staff interviews revealed that the Broda chair was used for the resident without a prior therapy assessment or documented PT referral. An LPN acknowledged that the resident had not been assessed for use of the Broda chair before it was used. A restorative CNA reported being unaware of the resident using a Broda chair and stated the resident used a regular wheelchair and was able and preferred to stand. A PTA explained that when a Broda chair is considered, nursing is expected to submit a PT referral for an assistive device evaluation, after which PT determines appropriateness and provides recommendations; she confirmed there was no PT referral for this resident and that she had never seen the resident in a Broda chair. During a joint interview with leadership staff, the LPN stated the Broda chair was used for comfort rather than mobility but acknowledged a PT referral should have been initiated, and the RN and Administrator agreed that an assessment should have been completed in accordance with policy. These findings show the resident used a Broda chair without the required assessment to determine appropriateness, need, and safe use.
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