Failure to Follow Through on Custom Wheelchair Order and Accommodate Resident Mobility Needs
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s need for a customized wheelchair despite an active physician order and documented discomfort with the current wheelchair. The resident had a history of hemiplegia and hemiparesis following a stroke, muscle wasting, COPD, chronic pain, and dependence on staff for transfers and most ADLs. The care plan identified hemiplegia/hemiparesis, pain management needs, dependence for mobility and repositioning, and the use of a wheelchair, with an order dated 01/22/26 for a custom wheelchair for proper positioning related to right hemiplegia and hemiparesis. Nursing documentation noted the resident reported back pain from lying on his/her back most of the time and that using the wheelchair at times helped relieve some pain. During interview, the resident stated the current wheelchair was uncomfortable, that he/she could only tolerate sitting in it for about 20 minutes before needing to return to bed due to pain, and that staff had largely stopped asking him/her to go to the dining room after multiple refusals. The facility’s own Durable Medical Equipment policy outlined detailed requirements and processes for obtaining custom wheelchairs, including physician face-to-face examinations, therapy evaluations, ATP involvement, prior authorization, and documentation standards. However, staff interviews revealed confusion and lack of clarity about the internal process for ordering and following through on a custom wheelchair, particularly for residents not currently on therapy. The physical therapy director reported that a custom wheelchair request originated around June 2025 during a care plan meeting, that he/she completed at least one evaluation and a wheelchair form, and placed the form in a physician’s folder for signature. He/she stated that for several weeks he/she moved the form to the front of the physician’s folder, later found the papers missing, and assumed the form had moved forward in the process. When a nurse practitioner later asked for the form and reported not having seen it, the therapy director completed another form and again placed it in the same physician’s folder. The therapy director stated he/she does not usually receive signed forms back and did not know whose responsibility it was to complete the process after the physician signed. Multiple staff members, including the DON, social services director, business office manager, and administrator, gave inconsistent or incomplete descriptions of who was responsible for ordering and tracking the custom wheelchair. The DON stated he/she did not know the facility’s process for assisting residents with obtaining a customized wheelchair, believed therapy “headed that up,” and thought social services might be involved but was unsure. The social services director, who had been in the role for three weeks, reported not knowing the process for ordering a custom wheelchair, not being aware of any medical equipment ordering policy, and deferring questions to the administrator or business office manager. The business office manager stated that wheelchair orders go through therapy and that he/she had no paperwork regarding the custom wheelchair order dated 01/22/26. The administrator stated that the DON should be following and reviewing physician orders to ensure they are carried out, acknowledged there was an active order for a custom wheelchair in the chart, and was unsure if anyone was working on obtaining it or what had happened after therapy contacted the equipment company. The medical director confirmed signing an order for a custom wheelchair in January 2026 and said he/she expected the wheelchair to be in place by now, but there was no documentation in the record of his/her follow-up call to a wheelchair company. Overall, there was no documentation in the resident’s record or in facility files showing that the custom wheelchair order had been processed, tracked, or completed, resulting in the resident continuing to use an uncomfortable standard wheelchair and remaining largely bedbound despite an order and policy framework intended to support provision of a custom wheelchair. Additional interviews further illustrated the lack of follow-through and coordination. The physical therapy director reported that the resident had at times expressed liking the existing wheelchair to him/her while telling family it was uncomfortable, that the resident had refused trying a larger facility wheelchair offered as a trial, and that the resident had long periods of remaining in bed, including about eight months when he/she did not get out of bed. The therapy director also stated that he/she recalled telling the family they would need to pick a wheelchair company but never heard back, and that he/she had no paperwork in the therapy file related to the custom wheelchair process. Nursing staff, including an RN and an LPN, reported not being aware of the resident requesting or needing a new wheelchair and noted that the resident rarely got out of bed, typically only for showers, with transfers requiring a Hoyer lift and two staff. The DON stated that therapy had indicated they could not get the resident out of bed and therefore saw no need for a new wheelchair, and also stated that the resident did not qualify to have the wheelchair paid for, while acknowledging that he/she would expect the January 22 order to be resolved or at least have documented progress. Collectively, these actions and inactions show that despite an identified need, an active physician order, and a facility policy describing the process for obtaining custom wheelchairs, the facility did not ensure that the resident’s custom wheelchair was ordered, tracked, and obtained, and did not reasonably accommodate the resident’s need for appropriate seating and mobility. Staff interviews also showed that the facility lacked a clear, consistently understood process for ordering and tracking custom wheelchairs. The physical therapy director described a general sequence of identifying need, performing a wheelchair evaluation, contacting a medical supply company, completing forms, and placing them in a physician’s folder, but could not identify who was responsible for subsequent steps after physician signature. The DON believed therapy initiated the process and that the family would select the DME company, while the administrator stated that the social worker had no role and that equipment would be ordered by maintenance, the DON, and/or the administrator. The social services director believed maintenance ordered beds and similar equipment and that any resident equipment needs would be cleared through the administrator. No one could produce a policy specific to physician orders or a documented workflow for custom wheelchair procurement. This lack of defined responsibility and documentation resulted in the resident’s custom wheelchair order remaining unresolved for an extended period, despite the resident’s ongoing discomfort and limited tolerance for the existing wheelchair.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to provide requested enabler bars: A resident with HF, HTN, and renal insufficiency was assessed by OT as needing assist bars for bed mobility, but the resident remained without enabler bars despite stating she had requested them since admission. Nursing and OT staff confirmed the bars were not in place, and OT indicated the observation/order process likely was never entered.
Call lights were not kept within reach for five residents reviewed for residents' rights. Residents with diagnoses including bipolar disorder, stroke, TBI, Alzheimer's disease, schizophrenia, PTSD, diabetes, schizoaffective disorder, OCD, and unsteadiness on feet were observed with call lights placed under beds, hung on wall hooks out of reach, or coiled and pinned so they could not independently access them. An LPN and the DON stated the call lights should have been within the residents' reach.
A resident with a Right Femur Fracture, Anxiety Disorder, and moderate cognitive impairment was repeatedly observed in bed with the call light clipped onto itself at the head of the mattress, out of view and reach. The resident could not identify how to contact staff at times and stated they wanted the call light where they could see and reach it; the UM and DON confirmed call lights are to be kept within resident reach.
A resident with moderate cognitive impairment and significant care needs had ongoing difficulty using the standard call light, but the record had no formal assessment of call light ability and no adaptive call light was tried. The resident and family reported delayed responses and confusion about whether the call light had been activated, while an NA said the resident complained almost daily that staff did not answer. The DON confirmed the resident did not like a pancake call light, but no formal assessment had been completed.
A resident with intact cognition, generalized weakness, and COPD was found in bed on multiple observations with the call system device tucked inside the nightstand drawer and out of reach. The care plan directed staff to keep the call light within reach, and the DON confirmed it should have been placed within the resident’s reach.
A resident with paraplegia and bilateral above-the-knee amputations was observed in bed with his call light on the floor and out of reach on multiple occasions. He was alert and oriented, able to use the call light, and stated he could not reach it to ask for help with his menu, nasal cannula, or breakfast. Staff confirmed the call light should have been within his reach, and the facility policy required call lights to remain within reach for residents able to use them.
Failure to Provide Requested Enabler Bars
Penalty
Summary
The facility failed to reasonably accommodate Resident R105’s need and preference for enabler bars on the bed. The resident was admitted with diagnoses including heart failure, high blood pressure, and renal insufficiency. An OT evaluation dated 7/22/26 documented that the resident required assistance with bed mobility and could complete it with stand-by assistance if assist bars were present, but the resident’s clinical record on 8/5/26 did not include an observation for enabler bars. During an observation on 8/3/26, Resident R105 was lying in bed and stated she wanted enabler bars to help position herself in bed and had asked for them since admission but had not heard back. An RN confirmed the resident did not have enabler bars and said she would look into it. On 8/5/26, the resident was again observed resting in bed without enabler bars. An OT employee stated the process was for therapy to determine whether residents could use their upper extremities, then nursing would enter an observation for enabler bars and maintenance would be notified, and another OT employee stated the resident would benefit from enabler bars and that the observation probably never got entered into the computer.
Call Lights Not Within Reach for Multiple Residents
Penalty
Summary
The facility failed to ensure call lights were within reach for 5 of 18 residents reviewed for residents' rights: Residents #29, #50, #51, #56, and #57. The facility's policy, "Answering the Call Light," revised September 2022, stated that call lights should be accessible to residents when in bed, from the toilet, from the shower or bathing facility, and from the floor. Resident #51, who had diagnoses including acquired absence of the left leg below the knee, bipolar disorder, and anxiety disorder, was observed with the call light button under the bed against the wall and not accessible. Resident #56, who had diagnoses including stroke, traumatic brain injury, and Alzheimer's disease, was observed lying in bed without the call light button, which was hanging on a wall hook about five feet high and out of reach; she was unable to self-ambulate, could not get out of bed, and did not verbally communicate. Resident #29, who had diagnoses including schizophrenia, PTSD, and diabetes, was observed with the call light plugged into the wall above the bed, hanging down to the floor under the bed and not within independent reach. Resident #57, who had diagnoses including schizophrenia, anxiety, and unsteadiness on feet, was observed with the call light plugged into the wall above the bed with the cord coiled and pinned to itself and not within independent reach. Resident #50, who had diagnoses including schizoaffective disorder and OCD, was observed with the call light plugged into the wall near the foot of the bed, coiled and pinned to itself and not within reach. Staff interviews confirmed the call lights for these residents should have been within reach and were not.
Call Light Not Kept Within Resident Reach
Penalty
Summary
The facility failed to ensure that R15’s call light was kept within reach. On 07/28/2026, R15 was observed lying in bed with the call light hanging over the top left edge of the head of the bed and clipped onto itself at the side of the mattress, out of view and reach. When asked how they would contact staff for assistance, R15 could not provide a response, and when asked about the call light, stated that sometimes it was with them but not always. R15’s EMR showed admission to the facility with diagnoses including Right Femur Fracture and Anxiety Disorder. The MDS indicated moderate cognitive impairment and maximum assistance with most self-care tasks, and the ADL care plan included the intervention to encourage use of the call light and keep it within reach. On 07/29/2026 and 07/30/2026, R15 was again observed with the call light clipped onto itself on the left side of the mattress at the head of the bed, out of the resident’s view and reach. R15 stated they did not know where the call light was and said they would prefer to be able to see and reach it. The UM and DON both confirmed that call lights are to be kept within resident reach, and the facility policy for unit rounds included checking that the call light was placed appropriately.
Failure to Assess Call Light Use and Provide Adaptive Call Light
Penalty
Summary
The facility failed to assess a resident’s ability to independently activate the call light and did not provide a reasonable accommodation, such as an adaptive call light, after staff became aware of ongoing difficulty using the standard call system. The resident had a quarterly MDS identifying moderate cognitive impairment and diagnoses including chronic kidney disease, a sacral pressure ulcer, atrial fibrillation, and hypertension. The resident required substantial to maximal assistance with bathing and was dependent on staff for all other care areas, with a care plan directing staff to respond promptly to toileting requests, provide a bedpan when safely possible, and keep the call light in reach. During interview, the resident stated she could push the call button but staff did not come for over two hours, while a family member said the resident had difficulty pushing the call light at times and sometimes believed it had been activated when it had not. The resident’s record contained no assessment of call light ability. A nursing assistant reported the resident complained almost daily that she had turned on the call light and staff did not answer, and said this had been reported to nursing without change. The DON stated the resident had complained of long wait times, but call light logs showed the resident had not turned on the call light; the DON also stated the resident did not like a pancake call light, yet no formal call light assessment had been completed and no different adaptive call light had been tried.
Call Light Not Kept Within Resident’s Reach
Penalty
Summary
The facility failed to ensure that a call system was accessible for one resident who had diagnoses including high blood pressure, prostate cancer, generalized muscle weakness, and COPD. The resident’s MDS assessment dated May 11, 2026, showed intact cognition and dependence on staff for activities of daily living, including toileting, dressing, and personal hygiene. The care plan identified the resident as at risk for falls and directed staff to keep the call light within reach for assistance as needed. However, on multiple observations, the resident was found in bed with the call system device tucked inside the top drawer of the nightstand, out of reach. The DON confirmed that the call system device should have been placed within the resident’s reach.
Call Light Left Out of Reach
Penalty
Summary
The facility failed to ensure that Resident 121’s call light was within reach so he could summon staff assistance. Resident 121 had diagnoses of paraplegia, left above-the-knee amputation, and right above-the-knee amputation. His baseline care plan documented that he was a fall risk, that staff should anticipate and meet his needs, and that he did not have cognitive impairment. A daily skilled note documented that he was oriented to person, place, time, and situation but required supervision for safety. During observations, Resident 121 was found lying in bed with his call light on the floor and out of reach on two separate occasions. On one observation, he had his breakfast tray on the over-bed table with a pencil and paper to complete his menu, but he stated he could not reach the call light to ask for help because it was on the floor. On another observation, he again could not reach the call light and stated he could not use it to ask for help with his nasal cannula or to ask about breakfast before leaving for an appointment. Staff interviews confirmed that he was able to use his call light and that it should have been within his reach at all times. The facility policy stated that staff would ensure call lights were within reach of residents who were able to cognitively use them each time staff left the room.
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