Failure to Assess and Provide Safe Wheelchair Equipment
Penalty
Summary
Facility staff failed to ensure that residents received appropriate and safe wheelchair equipment in accordance with orders and resident preferences. For one resident, a concern form documented a request for footrests for the resident’s wheelchair. The Rehab Director reported difficulty finding leg rests that fit because the wheelchair prongs were wider than standard and the leg rests would not stay in place. The Rehab Director stated they tried modifications to keep the pieces together and that the resident’s legs were propped on chairs when their legs became tired during therapy. However, there was no documentation showing efforts to obtain appropriate footrests, and the Rehab Director acknowledged they were only searching online and had not contacted a supply company. For another resident, the resident reported that their wheelchair did not lock and that the armrest would not lock, and they verbalized feeling unsafe when transferring from the wheelchair to the commode. The Rehab Director stated that wheelchairs typically came from other residents and were turned over quickly, and acknowledged that this wheelchair had not been assessed for safety before being provided to the resident. The Rehab Director explained that the armrest release needed to be spun for the armrest to function properly and that the wheelchair brake appeared bent and had been bent back that morning. These observations and interviews showed that the facility did not assess wheelchair safety or ensure necessary equipment was available before use by the residents.
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