The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Based on interview and record review, the facility failed to ensure a complete and final assessment of the availability of appropriate Durable Medical Equipment (DME) Services services in the form of a promised wheelchair replacement to meet identified needs following hospitalization for 1 of 5 sampled patients (#4).


Patient #4's medical record contained an Emergency Department (ED) physician's note on 5/11/21 at 7:22 AM which read, "male with a complex past medical history .... presents for evaluation of PEG (Percutaneous Endoscopic Gastrostomy) tube dislodgment." Orders for admission were placed on 5/11/21 at 9:56 AM.

A physician's note of 5/14/21 at 11:03 AM read, "Appropriate equipment and supplies have been obtained for patient to be discharged home with."

On 5/12/21 at 10:44 AM, the case manager indicated that the patient has a specialty wheelchair and walker.

On 5/13/21 at 2:32 PM, the Social Worker (SW) wrote, "Daughter also informed that patient came in with a wheelchair which is now missing, as she said it did not go up to.... tower from the ED. ANOM (Assistant Nursing Operations Manager)....was unable to find the wheelchair. CM (Case Management) informed daughter that a new wheelchair can be provided." Thus, facility staff had made a commitment to the patient's family, while the patient was still in the facility, to supply a replacement wheelchair. At 3:38 PM, the SW wrote, "CM (Case Management) ....ordered wheelchair to be delivered at bedside.... since patient's wheelchair was lost during admission. No orders for DME were entered, however, this will be billed to DC (Discharge) Support regardless."

On 6/17/21 at 12:15 PM, the Risk Manager stated that the patient's original wheelchair was lost during the patient's stay. She stated that this matter was a complaint as filed during the patient's stay. She stated that they offered the patient three wheelchairs: a standard one which the family said was too small, a bariatric wheelchair which the family said was too big, and a different brand of standard wheelchair which was also rejected. She stated that these offerings were made while the patient was still in the facility. She stated that there was an understanding between the facility and the patient's family that a wheelchair meeting their requirements would be delivered after discharge. She stated that the Case Manager left messages with a DME company for the home delivery of the wheelchair. However, she never received any calls back to confirm the order, and said no one checked on the order status. She confirmed that a wheelchair was never delivered. The facility did not follow through with its commitment for supplying DME as promised during discharge activities.