Failure to Adequately Supervise Unsafe Power Wheelchair Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and implement appropriate safety interventions for a resident who operated a power wheelchair at excessive speeds inside the facility despite multiple OT assessments identifying him as unsafe and recommending restriction of power wheelchair use to outdoor areas only. The resident, admitted and re-admitted with diagnoses including COPD, hypertension, and muscle weakness, had intact cognition per a quarterly MDS. OT progress notes documented that the resident hit a door and ran over someone’s foot while driving his scooter, was very impulsive, and showed aggressive behavior quickly. Social Services, the Therapy Director, and the Nurse Unit Manager met with the resident to discuss safety concerns and offered a more appropriate wheelchair, which he declined, and informed him that further incidents would result in removal of the scooter. Subsequent OT notes showed repeated safety education and training, with the resident continuing to demonstrate poor maneuverability skills, refusing to adhere to appropriate facility speed settings, and being recommended to use the power scooter only outside the facility while using a manual wheelchair safely indoors. Further documentation and interviews showed ongoing unsafe operation of the scooter within the facility. OT notes indicated poor safety awareness, including attempts to fit through doorways that were too narrow. A CNA reported that the resident had previously run full speed into her leg with the scooter, fracturing her leg, and that she had seen him run into other people, and also reported a lack of staffing on a specified shift. Multiple observations on survey dates showed the resident speeding down hallways with the scooter set on the highest (rabbit) mode. Staff interviews confirmed that the resident “always” sped down the hall, that staff educated him but he refused to cooperate, and that he was stubborn and would not give up the scooter. The scooter was observed to be heavily damaged in the front, with the resident stating he had run into something he could not remember and that his hand had gotten stuck in the trigger area, while the scooter was again noted to be set at the fastest speed. These findings demonstrate that the resident continued to operate the power scooter unsafely inside the facility without effective supervisory or safety interventions being implemented.
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