Health inspection·July 11, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on review of manufacturer's directions for use, investigative reports, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident environment remained as free from accident hazards as possible by failing to follow the manufacturer's directions for use of a high-back reclining wheelchair for one of three residents reviewed (Resident 1), resulting in a fall. Findings include: Operation instructions for the Medline Standard Manual Wheelchairs, dated December 30, 2021, revealed that to ensure safety in using this Medline wheelchair, all warnings and safety information and all instructions must be followed. Failure to do so may result in serious bodily injury or damage to the chair. Recliner models only: DO NOT use the recliner wheelchair without the anti-tip devices installed. Anti-tippers MUST be always attached, and both must be adjusted to the same height. Ensure the anti-tippers are secured as evidenced by the spring buttons fully protruding out of the holes. Anti-tippers (included with select models): Rear anti-tippers help keep the chair from tipping and are recommended attachments for additional safety. The use of anti-tippers is required on all recliner models. Recliner operation (recliner models only) WARNINGS: Anti-tippers MUST be always attached. Ensure both ant-tippers are adjusted to the same height. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated June 27, 2024, revealed that the resident was usually understood and could usually understand others, and had a diagnosis which included cerebral vascular accident (CVA commonly known as a stroke) and Parkinson's disease. A care plan for the resident, dated May 30, 2024, revealed that the resident had an actual skin impairment to his right second toe and right heel, and that the resident was to utilize a high-back reclining wheelchair with wedge cushion (gently tilts the hips, pelvis and spine forward) and foot buddy (cushioned back and side panels prevent feet from slipping off footrests) for out-of-bed positioning. An occupational therapy note for Resident 1, dated May 1, 2024, revealed that the resident demonstrated fair to poor positioning in a standard wheelchair with a foot buddy, wedge cushion, and backrest cushion. Resident 1 reported back pain and was requiring an adjustment in his wheelchair when assessed. The plan was to contact the medical supplier to acquire a high-back reclining wheelchair that the resident can self-propel with necessary back support. The current backrest support was not sufficient to reduce out-of-bed pain/discomfort. An occupational therapy note for Resident 1, dated May 23, 2024, revealed that the resident trialed a 20-inch high-back reclining wheelchair this date with good upright positioning following the Page 1 of 2 396088 396088 07/11/2024 Maple Winds Healthcare and Rehabilitation, LLC 4112 Spring Hill Road Portage, PA 15946

F 0689 Level of Harm - Minimal harm or potential for actual harm initial adjustment. Food buddy, wedge cushion carried over, and bilateral elevating leg rests adjusted to the most appropriate length. Because the resident's wheelchair brakes were found to be in good working order without reoccurring issues, and there were no attempts at self-transfers noted, the anti-rollback system (a weight-sensitive braking mechanism that automatically locks rear wheelchair wheels when a resident stands) was no longer indicated. Residents Affected - Few Physician's orders for Resident 1, dated May 28, 2024, included an order for the resident to utilize a high-back reclining wheelchair with wedge cushion and foot buddy for out-of-bed positioning. A progress note for Resident 1, dated June 20, 2024, revealed that the resident was in his special wheelchair in A hall self-propelling towards the nursing station when his chair fell straight back. His head appeared to have hit the little pillow connected, not the floor, but they cannot be sure. The resident stated, I fell! The resident was set up while still in the wheelchair by five staff members. An interdisciplinary team note for Resident 1, dated June 21, 2024, revealed that therapy reviewed the resident's wheelchair, and the anti-tippers were adjusted to be closer to the floor. Camera footage was also examined and confirmed that the resident was self-propelling in the hallway and was noted to tip backwards while self-propelling. An occupational therapy screening note for Resident 1, dated June 21, 2024, revealed that the resident's wheelchair had tipped backwards on the previous evening. The wheelchair was assessed and found to be in good working order. The anti-tippers were adjusted to the downward position to prevent future tipping. The wheelchair was not able to be tipped backwards when assessed. Will continue to monitor. Interview with Occupational Therapist 1 on July 11, 2024, at 9:05 a.m. revealed that Resident 1 was placed in the high-back reclining wheelchair due to having a lot of back pain. He indicated that when the wheelchair arrived at the facility, he would have been the one to go over the wheelchair prior to the wheelchair being given to the resident. He indicated that after the incident on June 20, 2024, he performed an evaluation of the resident's wheelchair and noted that the rear anti-tippers on the wheelchair were installed upside down. He indicated that the wheelchair came that way from the manufacturer. He confirmed that during the initial evaluation he missed that the rear anti-tippers were not installed properly and he did not install them properly until after the incident. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing Services. 396088 Page 2 of 2