Resident Placed in Damaged, Misassigned Wheelchair Contrary to Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe, clean, comfortable, and homelike environment for a resident who relied on a wheelchair as the primary mode of locomotion. The facility’s own policy stated that the Rehabilitation Department would identify appropriate wheelchairs and that unsafe equipment would be removed from service until repaired or discarded. Despite this, a resident with anemia, dementia, and heart failure, whose most recent MDS documented severely impaired cognition and wheelchair use for mobility, was observed seated in a wheelchair that was labeled with the name of another resident who no longer resided in the facility. During the observation in the dining room, the resident appeared visibly upset and pointed to the armrests of the wheelchair. The wheelchair was too wide for the resident and had damaged armrest padding, including one missing armrest pad and one frayed armrest pad. The RN Unit Manager present at the time stated they did not know how the resident came to be seated in that wheelchair, acknowledged that the wheelchair was damaged and did not belong to the resident, and indicated that the assigned CNA was on lunch and they would need to investigate how the resident was placed in that chair. The CNA later reported that at the start of the shift the resident was already in that wheelchair, that they used the same wheelchair throughout the morning for care and after a shower, and that they had not checked the name on the wheelchair or noticed the damage. The Director of Therapy confirmed that the wheelchair was not assigned to the resident, was too wide, and was not suitable for any resident due to its damaged condition, and stated that no resident should be seated in that wheelchair and that it should not have been on the unit. The Director of Therapy also stated that when a resident is discharged, the resident’s wheelchair should be removed from the unit and that all wheelchairs should be labeled with the resident’s name, but they were unable to locate the resident’s actual wheelchair. The Director of Maintenance reported being unaware that the resident’s wheelchair was damaged and stated that maintenance does not perform routine inspections of wheelchairs, relying instead on nursing staff to report damage, and that there was no system in place to routinely identify damaged wheelchairs.
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