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:
A resident with dementia, severe cognitive impairment, limited lower extremity range of motion, and a need for assistance with ADLs was twice observed lying in bed without an accessible call light, which was either hanging under the head of the bed or tucked between the mattress and bedframe. An LVN confirmed the resident could use the call light if available, and a CNA, another LVN, the DON, and the ADM all stated that call lights should always be within reach, that all staff are responsible for ensuring access, and that they were unaware this resident’s call light was not in reach. This was inconsistent with the facility’s policy requiring each resident to have a means to call staff directly for assistance from the bed and other areas.
Failure to accommodate a resident with severe vision loss included staff placing breakfast on his bedside table without consistently telling him what food was on the tray, where it was located, or removing cellophane from items. The resident said he could not read the papers given to him, and the activity calendar in his room was not in large print. Staff interviews were inconsistent about whether he was routinely oriented to his meal and whether he received large print reading materials.
A resident with dementia, schizophrenia, neurocognitive disorder, severe cognitive impairment (BIMS 03), and total dependence on staff for ADLs was observed in bed wiggling and calling out without a call light within reach; the call light was found on the floor beside the nightstand. The resident’s care plan documented inability to use the call light due to dementia and required the call light to be reachable for family or staff to request assistance, with frequent monitoring and rounding. The ADON stated that a CNA had not ensured the call light was in reach, and the CNA reported the resident’s movement during repositioning likely caused the call light to fall, acknowledging it should have been accessible. The DON and facility policy both specified that staff must ensure call lights and frequently used items are within residents’ reach each time staff leave the room.
A resident with multiple cardiac and visual diagnoses, who required assistance with mobility and used an air mattress, repeatedly requested bed handrails due to a fear of falling out of bed. Staff reportedly told the resident that handrails were not allowed, and the facility had a practice of not using handrails with pressure-reducing air mattresses without performing individualized assessments. Despite the resident’s documented care needs and known fear of transfers, there was no assessment, care plan intervention, or evaluation in the medical record addressing the request for handrails, even though facility policy and manufacturer guidance called for individualized assessment of bedrail use.
A resident with muscle weakness, diverticulitis with perforation and abscess, and moderately impaired cognition, who required varying levels of assistance with ADLs, was observed in bed with the call light not within reach, hanging behind the headboard. During a subsequent observation and interview, an LVN confirmed the call light was out of reach and repositioned it next to the resident’s hand, stating call lights should always be next to residents and that CNAs are responsible for ensuring accessibility. The DON later affirmed that call lights must be clipped by the bed and within reach so residents can call for assistance, and facility policy requires staff to ensure the call system is accessible to residents while in bed.
A resident with chronic kidney disease and chronic atrial fibrillation was observed lying in bed with the call light plugged into the wall and hanging under the head of the bed, out of reach, and the resident could not independently access it. An RN and the RCN each acknowledged that the call light should have been within the resident’s reach and that it was not, resulting in a failure to reasonably accommodate the resident’s needs and preferences.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach, as required by facility policy and staff training. An elderly female resident with dementia, severe cognitive impairment (BIMS score of 03), limited range of motion in both lower extremities, and a need for partial/moderate assistance with ADLs was observed on two separate occasions without accessible call light access. On one observation, the resident was lying in bed with the call light hanging on the bed frame under the head of the bed; on another, the call light was tucked between the mattress and bedframe at the head of the bed, making it unavailable for use. Multiple staff interviews confirmed that the call light should always be within reach of residents and that there was no reason this resident should not have had access to it. An LVN stated the resident was able to use the call light if it was available and that it should always be in reach. A CNA, another LVN, the DON, and the ADM each stated that the purpose of the call light was for residents to call for assistance, that all staff had been trained on call light placement, and that all staff were responsible for ensuring residents had access to the call light. None of them were aware that this resident’s call light was not within reach. The facility’s written policy on the resident call system stated that each resident is to be provided with a means to call staff directly for assistance from the bed and toileting/bathing areas, which was not followed in this case.
Failure to Accommodate a Visually Impaired Resident’s Meal and Reading Needs
Penalty
Summary
Reasonably accommodate the needs and preferences of each resident was not provided for a resident with severe visual impairment and severe cognitive impairment. The resident’s face sheet reflected diagnoses including blindness in the right eye and blindness in the left eye. The MDS documented that he was highly visually impaired and could see large print but not regular print in newspapers or books, and that reading books, newspapers, and magazines was very important to him. His care plan addressed visual impairment related to glaucoma and eye pressure, but there was no focus area addressing activities. During observation, the resident’s breakfast tray was placed on his bedside table while he sat on the edge of his bed. The tray contained grits, scrambled eggs, toast, a plastic cup of juice covered in cellophane, and a closed plastic container of grape jelly. The resident stated staff brought his tray, left the room, and did not tell him what food was on the tray or where it was located. He said he did not know he had juice and requested help removing the plastic. He also stated he was trying to eat because he did not want to lose any more weight and asked the surveyor to tell him where his food was on the tray. The resident further stated that the facility did not do anything to facilitate blind people and that papers dropped off for resident council were not in large print and he could not read them. Observation of the activity calendar in his room showed it was not in large print and he was unable to read it. Staff interviews were inconsistent: one OT said aides had been dropping off food without orienting him to it, while other staff said they told him what food was on his plate and where it was located. The ADM was not sure whether he received large print reading materials, and the VPC stated the activity calendar should be in large print so he could read it.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
Surveyors identified a failure to reasonably accommodate a resident’s needs and preferences by not ensuring her call light was within reach. The resident was an elderly female with dementia, schizophrenia, type 2 diabetes mellitus, neurocognitive disorder, cognitive communication deficit, and arthritis, who was re-admitted in late April 2026 and served as her own representative. A quarterly MDS dated 4/13/2026 documented a BIMS score of 03, indicating severe cognitive impairment, and showed she was totally dependent on staff for toileting, showering, dressing, and locomotion, using a wheelchair. Her care plan problem stated she was unable to use the call light due to dementia, with a goal that the call light be reachable for family or staff to request assistance, and an intervention of monitoring and rounding frequently. On 4/28/2026 at 12:04 p.m., surveyors observed the resident in bed in her room, wiggling and calling out, with no call light within reach; the call light was found on the floor beside her nightstand. At 12:05 p.m., the resident stated she wanted cookies and milk. The ADON stated that CNA A must not have placed the call light within reach when assisting the resident and confirmed that call lights were to be in reach of all residents, including this resident. At 12:30 p.m., CNA A reported he was unaware the call light was not within reach, acknowledged it should have been, and explained the resident moved a lot in bed during repositioning and the call light must have fallen; he also stated the resident could have tried to get out of bed unassisted and hurt herself. On 4/29/2026 at 3:30 p.m., the DON stated staff were expected to ensure all frequently used items, including the call light, were within reach each time they exited a resident’s room, and that although this resident would normally call out if she needed something, the call light still needed to be within reach. Facility policy dated 10/13/2022 required staff to ensure call lights were within reach of residents and secured as needed.
Failure to Assess and Accommodate Resident Request for Bed Handrails
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s expressed need and preference for bed handrails by not conducting an individualized assessment or evaluation. Resident #43, admitted with diagnoses including total retinal detachment of the left eye, asthma, chronic ischemic heart disease, and acute on chronic systolic heart failure, had an air mattress ordered for skin prevention and required assistance with bed mobility, transfers, toileting, dressing, and hygiene. The resident’s care plan identified a two-person assist for transfers and noted behavioral issues related to refusals of treatment and a preference for keeping the bed in the highest position despite education on fall risks. However, the medical record contained no documented assessment, care plan intervention, or evaluation related to the resident’s request for handrails to address a fear of falling. During observation and interview, the resident reported a longstanding fear of falling out of bed and stated he had been requesting handrails for approximately one year, but staff told him that “state would not allow handrails” and no assessment had been completed. At the time of observation, the resident’s bed had an air mattress and no handrails. The Administrator and DON stated that residents with pressure-reducing air mattresses automatically did not have handrails due to entrapment risk and confirmed the facility did not perform individual risk assessments for handrails when an air mattress was in use, despite staff being aware of the resident’s fear of transfers since admission. The Administrator later acknowledged that the medical record lacked documentation of any assessment or interventions related to the handrail request and that both facility policy and the air mattress manufacturer’s guidance required individualized assessment of bedrail use based on the resident’s physical and mental status.
Failure to Keep Call Light Within Reach of Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach while the resident was in bed. The resident had been originally admitted in late January and re-admitted in late April with diagnoses including muscle weakness and diverticulitis of the large intestine with perforation and abscess with bleeding. An MDS assessment indicated the resident had moderately impaired cognitive skills for daily decision-making, required setup or clean-up assistance with eating, supervision with oral hygiene, partial/moderate assistance with toileting hygiene, and substantial/maximal assistance with showering or bathing. During an observation in the resident’s room, the resident was seen in bed with the call light not within reach, hanging on the wall behind the headboard. In a concurrent observation and interview with an LVN in the same room, the resident remained in bed with the call light still not within reach, again observed hanging behind the headboard. The LVN then reached over the headboard, clipped the call light, and placed it next to the resident’s right hand, stating that the call light should always be next to the resident for safety and that CNAs are responsible for ensuring call lights are within residents’ reach because they are always checking on residents. In a separate interview, the DON stated that call lights should always be within residents’ reach, clipped by the bed, so residents can easily call staff when they need help or assistance, and that if call lights are not within reach, residents may not be able to call for assistance when needed. Review of the facility’s policy on call lights indicated staff will be educated on proper use of the call light system and must ensure the call light is within reach of the resident and accessible while the resident is in bed or other sleeping accommodations.
Call Light Not Kept Within Reach of Resident
Penalty
Summary
Surveyors identified a deficiency in which the facility failed to ensure a resident’s call light was within reach. The resident, who had been admitted with multiple diagnoses including chronic kidney disease and chronic atrial fibrillation, was observed on 4/29/26 at 7:51 AM lying in bed with the call light plugged into the wall and hanging down the wall under the head of the bed, out of the resident’s reach. The resident was unable to independently reach the call light. At 7:53 AM the same day, an RN confirmed that the call light should have been within the resident’s reach and acknowledged that it was not. Later that afternoon at 3:48 PM, the RCN also stated that residents’ call lights should be within reach and confirmed that in this instance it had not been.
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