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:
Call Light Out of Reach: A resident with acute cystitis with hematuria, DM, and cirrhosis was found sitting in a chair with the call light hanging on the wall and out of reach. The resident asked a surveyor to call staff, and later an RN and CNA entered the room after being notified. The CNA stated the resident could not reach the call light, which was on the other side of the bed and should have been within reach.
Call Light Not Within Reach: A resident with severe cognitive impairment and dementia was observed in bed with his call light on the floor and out of reach. The CNA stated she normally ensured the call light was within reach because he was a fall risk, but she had not checked it before leaving the room. The DON and ADM stated residents’ call lights should be within reach so they can request assistance when needed.
Call Light Not Kept Within Reach: A resident with hemiplegia, hemiparesis, and contractures had a call light observed coiled on the contracted side of the bed and hanging toward the floor, out of reach. A CNA stated the resident could not reach it, and an RN confirmed the facility policy required the call light to be within reach and secure as needed.
A facility failed to keep call lights within reach for two residents with care plans directing staff to ensure access to the device. One resident with intact cognition and impaired physical mobility was found unable to reach her call light while asking for help to use the bathroom, and an LVN found it on the floor. Another resident with dementia and generalized weakness was observed in bed with her special call light on the floor under the head of the bed, and the DON retrieved it and clipped it to her linen.
Call Light Not Within Reach: A resident with severe cognitive impairment, hemiplegia/hemiparesis, and extensive ADL dependence was observed in bed with his call light on the floor under the curtain and not within reach. The resident said he usually had the call light but did not remember when he last had it and would call out for help if needed. A CNA stated the call light should be within reach, another CNA said she may not have placed it there after giving the resident a shower, and the DON stated call lights are expected to always be within reach.
Failure to provide and document wheelchair positioning devices: A resident with moderate cognitive impairment, total assist transfers, and short stature was repeatedly observed seated in a high-back wheelchair with both legs dangling unsupported. OT had evaluated the resident and provided bilateral leg rests and a foot/calf board for lower-extremity support, but the devices were missing during observations and were not documented in the care plan, physician orders, or Kardex, so staff did not consistently accommodate the resident’s assessed positioning needs.
Call Light Out of Reach
Penalty
Summary
The facility failed to ensure Resident #38’s call light was within reach. Resident #38 was admitted with diagnoses including acute cystitis with hematuria, diabetes, and cirrhosis of the liver. On 7/10/26 at 9:14 AM, while three surveyors were passing by the resident’s room, Resident #38 asked one of them to call a staff member. The resident was sitting in a chair with a front wheel walker in front of her, and when asked where the call light was, she pointed to it hanging on the wall out of reach. Resident #38 stated she had been assisted to her room by staff after breakfast and had been sitting in the chair for a while. Later that morning, RN #1 and CNA #1 entered the room after being informed by the surveyor that the resident needed assistance. CNA #1 stated the resident was unable to reach her call light, which was on the other side of the bed, and acknowledged that it should have been within the resident’s reach.
Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure Resident #2’s call light was within reach while he was in bed. Resident #2 was admitted on 06/30/2026 and had a quarterly MDS showing a BIMS score of 03 out of 15, indicating severely impaired cognition. His diagnoses included non-Alzheimer’s dementia, and his care plan identified a communication problem related to dementia and a fall risk related to cognitive impairment, with interventions to keep the call light in reach and encourage its use for assistance. During an observation on 06/30/2026 at 04:46 PM, Resident #2 was sitting up in bed and his call light was on the floor and not within reach. Resident #2 stated he could not reach the call light and was unable to answer further questions about it. CNA C stated she normally ensured the call light was within reach because he was a fall risk, but she had not checked it before leaving the room earlier. The DON and ADM later stated that residents’ call lights should be within reach so they can request assistance when needed.
Call Light Not Kept Within Reach
Penalty
Summary
The facility failed to ensure that Resident 78’s call light was within reach. Resident 78 was admitted with diagnoses including hemiplegia, hemiparesis, contracture of the left shoulder, and type 2 diabetes mellitus. The resident’s MDS dated 4/13/2026 indicated moderate cognition with cognitive skills for daily decision making, and the resident required partial moderate assistance with eating, was dependent for personal hygiene, and needed help rolling left and right. The care plan, revised on 4/5/2025, identified an alteration in musculoskeletal status related to left knee contractures, left shoulder internal rotator contracture, and degenerative changes of the thoracic spine, and included interventions to anticipate and meet needs, ensure the call light is within reach, and respond promptly to requests for assistance. During a concurrent observation and interview on 6/29/2026 at 10:03 AM, Resident 78’s call light was observed coiled on the left side of the bed rails and hanging toward the floor. The CNA stated the call light was on the resident’s contracted side and that the resident was not able to reach it to call for staff when assistance was needed. An LVN later stated the call light should be on the resident’s right, dominant side so the resident could reach it and use it to call for help. An RN reviewed the facility’s policy on call light accessibility and stated staff are required to ensure the call light is within reach and secure as needed, and that the policy was not followed.
Call Light Not Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure the call light system was within reach for two residents reviewed for accommodation of needs. One resident had diagnoses including hypertension, neurogenic bladder, non-Alzheimer’s dementia, and generalized muscle weakness, with a BIMS score of 15 indicating intact cognition. Her care plan identified impaired physical mobility related to general weakness and directed staff to ensure the call light was available. During observation, she was sitting at the foot edge of the bed asking for help to use the bathroom, but could not reach the call light because it was laying on the floor beside the bed. An LVN entered the room after the roommate’s call light was pressed, found the call light on the floor, and placed it next to the resident in bed. A second resident had non-Alzheimer’s dementia and generalized muscle weakness, with a BIMS score of 06 indicating severe cognitive impairment. Her care plan addressed impaired cognition, memory loss, and impaired decision making, and included interventions to ensure the call light was in reach. During observation, she was lying in bed awake and watching TV, and her special call light device was on the floor under the head of the bed. The roommate’s call light was activated, and the DON entered the room, found the resident’s call light on the floor, and clipped it to her linen next to her. The DON and the Administrator stated that call lights needed to always be within residents’ reach, and the facility policy stated the call light should be accessible when in bed, from the toilet, from the shower or bathing facility, and from the floor.
Call Light Not Within Reach
Penalty
Summary
Reasonably accommodating resident needs and preferences was not provided for one resident when his call light was found on the floor underneath the curtain separating the room and was not within reach during an observation. The resident was a male with diagnoses including hypertensive heart disease, epileptic seizures related to external causes, depression, hemiplegia and hemiparesis following cerebral infarction, benign prostatic hyperplasia, and cognitive communication deficit. His quarterly MDS showed a BIMS score of 04, indicating severe cognitive impairment, and he was inattentive or had an altered level of consciousness. The MDS also showed he needed substantial to maximum assistance with 6 of 8 ADLs related to self-care. His care plan identified him as at risk for falls related to needing maximum assistance with ADLs and included an intervention to ensure his call light was within reach and to encourage him to use it for assistance as needed. During interview, the resident stated he usually had his call light but did not remember when he last had it, and said he did not think he could use it and would just call out for help if needed. A CNA stated the call light should be within reach and that all residents' call lights should be within reach. Another CNA stated she had given him a shower earlier and might not have put the call light within his reach, while the DON stated it was her expectation that call lights are always within reach of every resident and that all staff are responsible for ensuring this.
Failure to Provide and Document Wheelchair Positioning Devices
Penalty
Summary
The facility failed to reasonably accommodate a resident’s assessed need for assistive positioning devices while seated in a wheelchair. Resident 12 was admitted with diagnoses including adult failure to thrive, bipolar disorder, and PTSD, and a quarterly MDS dated May 7, 2026 showed moderate cognitive impairment with a BIMS score of 9 and total staff assistance required for transfers. The resident was 55 inches tall. On June 28, 2026, the resident was observed seated in a high-back wheelchair with both legs and feet dangling 16-18 inches above the floor without support. Clinical records showed Occupational Therapy completed a wheelchair analysis on April 22, 2026 and documented that the resident was provided a new high-back wheelchair with bilateral leg rests and a foot/calf board to increase lower extremity support. However, the OT discharge summary did not identify the specific adaptive equipment and positioning devices needed to maintain the seated posture goal. A second observation on June 29, 2026 again showed the resident in the same wheelchair with both legs unsupported and dangling. The COTA confirmed the leg rests and foot/calf board were missing and not present in the room. The DOR stated OT had evaluated the resident’s seating and positioning needs and provided the wheelchair, leg rests, and foot/calf board because the resident’s feet could not reach the floor, but there was no documented evidence these devices were incorporated into the care plan, physician orders, or Kardex. The facility therefore failed to communicate and implement the resident’s assessed positioning needs across disciplines, and staff did not consistently provide the necessary equipment while the resident was out of bed.
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