Improper Use of Wheelchair Lock as Physical Restraint During Meals
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from physical restraints not required to treat a medical symptom. The resident was admitted on 10/06/23 with diagnoses including unspecified dementia, hyperlipidemia, recurrent major depressive disorder, anxiety disorder, and cognitive communication deficit. A Minimum Data Set (MDS) assessment dated 02/02/26 documented that the resident was severely cognitively impaired, required set-up/clean-up assistance with eating, and was dependent for toileting, showering, and personal hygiene. The resident also exhibited occasional behaviors of physical aggression, verbal aggression, other behaviors, rejection of care, and wandering. On 03/11/26 at 10:34 A.M., the resident was observed alert, seated in a wheelchair at the dining room table, with the wheelchair locked on the left side. A subsequent observation at 11:49 A.M. the same day showed the resident still at the dining room table eating lunch in the same location, with the wheelchair again noted to be locked on the left side. During an interview at 2:22 P.M., a CNA stated that the resident was not able to lock or unlock the wheelchair and explained that staff locked the wheelchair to ensure the resident remained at the table and did not wander during meals. The CNA also verified that staff were not supposed to lock the wheelchair. The facility’s abuse and neglect policy states residents must be free from any physical restraint not required to treat a medical symptom, indicating that the practice of locking the wheelchair for behavior control was inconsistent with facility policy.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.