Failure to Implement Ordered Non-Slip Wheelchair Intervention for High Fall-Risk Resident
Penalty
Summary
Surveyors found that the facility failed to implement a care-planned fall intervention for a resident assessed as high risk for falls. The resident had dementia, repeated falls, generalized muscle weakness, difficulty walking, incontinence, and multiple co-morbidities, and was taking diabetic, blood pressure, narcotic, and psychotropic medications. A fall risk plan of care initiated on 11/11/22 identified the resident as at risk for falls related to weakness, co-morbidities, incontinence, and medication use, and an intervention dated 11/16/23 specified placing Dycem, a non-slip material, on the resident’s wheelchair. A physician order dated 11/05/23 also directed use of a non-skid sheet on the wheelchair. A fall risk evaluation dated 11/04/25 again identified the resident as high risk for falls, with risk factors including multiple recent falls, memory problems, frequent incontinence, behavioral issues, confinement to a chair, loss of balance when standing, need for hands-on assistance for mobility, use of an assistive device, and decreased muscle coordination, and it continued the intervention of Dycem to the wheelchair. During an observation and interview on 02/25/26 at 1:25 P.M., the resident was observed sitting in a wheelchair without Dycem or a non-skid sheet in place, despite the ongoing care plan and physician orders requiring this intervention. An LPN present at the time confirmed that the resident was in the wheelchair and that there was no Dycem present. This failure to implement the ordered and care-planned non-slip wheelchair intervention for a high fall-risk resident constituted the cited deficiency.
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