**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, visitor interview and resident interview the facility failed to provide Resident #19 with a reasonable accommodation of need that suited her preference for locomotion. Resident #19 had a motorized wheelchair that she had used for ten (10) years. The facility felt she was not safe to operate it anymore and took the batteries from the chair therefore disabling it. This left the feeling depressed and trapped as she had used this chair to travel throughout the facility. She suffered psychological harm due to this. This was true for one (1) of four (4) residents reviewed for the care area of abuse. Resident identifier: #19. Facility Census: 110. Findings included: a) Resident #19 On 05/23/23 at 3:51 PM it was brought to the attention of the survey team by a concerned visitor at the facility that Resident #19 had her motorized wheelchair batteries taken away from her several months ago and the facility would not return her batteries to her nor would they allow her to use her motorized wheelchair for mobility. The visitor indicated this had been Resident #19's only form of mobility since her admission to facility which was 10 years ago. A review of Resident #19's medical record beginning at 4:00 PM on 05/23/23 found Resident #19 was admitted to the facility on [DATE] at which time she used a motorized wheelchair for mobility to assist her in getting around the facility and for getting around in her room. Further review of the medical record found on 10/24/22 there was a physician order entered into the record discontinuing the use of the motorized wheelchair for Resident#19. An interview with Resident #19 at 3:37 PM on 05/24/23 revealed the following: When asked why she was no longer able to use her motorized wheelchair Resident #19 stated, A while ago I was down by the nurses' station in my wheelchair. The Med (Medication) cart was there and in the way. There was a gentleman who had his feet out blocking my way. Another woman was behind me and kept pushing on my wheelchair. I was afraid she was going to break my chair by pushing on it. I asked him to move his feet three times and he did not, so I ran over them. I did not have any other choice because the woman kept pushing on my chair and I did not want her to break my chair. Resident #19 continued to state that later that evening they took her battery and had not given it back since. When asked how losing her ability to use her motorized wheelchair made her feel she stated, I feel like I am trapped and have been in jail. The resident said, Nine (9) months is a long enough punishment for what I did don't you think. When it first happened, I was sad and now I am just angry because I cannot go like I was able to then. She further stated, They told me they would take me to all the activities, but they don't, there is not enough staff to get me there. She also stated, Physical Therapy asked me to give them my chair so someone else could use it, but it's my chair and I want to use it. The facility presented an incident report dated 10/22/22 for Resident #471, this incident indicated Resident #19 ran over Resident #471's feet with her motorized wheelchair. The incident report indicated Resident #19 was not paying attention while driving her motorized wheelchair as the cause of this accident. However, Resident #19's account of the incident does not indicate she was not paying attention. Her recount of the incident demonstrates there were several extenuating circumstances such as the medication cart being parked in the way, the resident being asked to move his feet and did not, and the other female resident who was continually pushing on the back of her wheelchair. The resident felt she made the only decision available to her because no staff was present to assist with eliminating any of the factors inhibiting her ability to pass by the area safely. The following pertinent information was obtained from Resident #471's medical record: A nurses note dated 10/22/22 at 7:17 PM which read as follows, This nurse informed by staff that resident of (room Number of Resident #19) ran over (First and Last Name of Resident #471) feet with motorized wheelchair. Resident stated both feet when asked by this nurse. Upon Assessment. No Redness, bruising, or swelling noted. Right Hallux began bleeding during assessment. This toe already had a band aid treatment in place. Right Hallux cleaned and new Band-Aid applied. Resident currently propelling self with legs down the hallway in wheelchair. Denies pain at present. Physician and Wife/POA notified. Additional note in Resident #471's record dated 10/23/22 at 6:28 PM read as follows, Results from X-ray of feet received. No acute fracture or dislocation. Findings consistent with gout. Resident #471's diagnosis included, Vascular Dementia with behavioral disturbance, lack of coordination, and anxiety disorder. On 05/24/23 at 10:33 am an interview with Occupational Therapist (OT) #172, confirmed Resident #19 was no longer allowed to use her motorized wheelchair. He stated they did evaluations on all residents who have a motorized wheelchair and the first thing they look at is decision making capacity. He stated if a resident loses capacity, they no longer can make right decisions. He stated there was also one (1) incident where the resident ran over someone's toes, and it coincided with the resident's annual assessment. He stated her scores on her cognitive tests had decreased so he referred her to the psychologist to evaluate her capacity. The Mental Health Nurse Practitioner evaluated the resident the following day on 10/14/22 and noted no issues with the resident using her motorized wheelchair nor any cognitive issues which would impair Resident #19's ability to make medical decisions. When asked if the reason Resident #19 was no longer allowed to use her motorized wheelchair was because she lost capacity to make medical decisions? OT #172 stated, Yes that is the main reason. Resident #19's medical record contained a Physician's Determination of Capacity indicating Resident #19 lacked capacity to make medical decisions. This capacity statement was dated 11/07/22. This was completed two (2) weeks after Resident #19's batteries were taken from her, and only three (3) weeks after the evaluation by the Mental Health Nurse Practitioner which noted no concerns related Resident #19's decision making ability. OT #172 was asked to provide copies of the cognitive tests he performed on Resident #19 which he spoke of during his interview. A review of these test found the following information (Please note all tests were performed prior to the incident which took place on 10/24/22): - Brief Interview of Mental Status (BIMS) : Score 13 of 15. This score indicates Intact Cognitive response. (Please note a review of the OT discharge summary for the dates of service from 09/28/22 - 10/13/22 indicated Resident #19's baseline score on the BIMS was 13 of 15 on 09/28/22 (which was one (1) month prior to Resident #19 being told she could no longer use her motorized wheelchair.) - Brief Cognitive Assessment Tool (BCAT): Score 33 of 50. This score indicates mild dementia. (This score was noted on 10/13/22) - St. Louis University Mental Status Exam (SLUMS): 14 of 30. This score indicates dementia. (This score was also noted on 10/13/22). During an interview with the Nursing Home Administrator (NHA) at 4:05 PM on 05/24/23 he stated, If a resident does not have decision making ability (Capacity to make medical decisions) they are not able to use a powered wheelchair because they cannot make safe decisions. That is how it has always been in this building; I just went along with it. I think there are other instances of her being unsafe I'll bring you the documentation. At the conclusion of the survey on 05/30/23 at 3:45 PM the NHA had not provided any further documentation to confirm Resident #19 had any other instances in her motorized wheelchair which made her unsafe to operate it other than the incident on 10/24/22. A further review of the medical record was completed on 05/24/23 and the following information was found: a nursing progress note dated 10/25/22 at 3:45 PM which read as follows, Spoke with friends of resident at residents request regarding her wheelchair that is motorized not being authorized for her use at this time due to safety concerns. (First and last name of Two (2) friends) contacted and returned the phone calls with social worker. Explained situation of resident running over other residents and bumping into doorways and walls and things in hallways and room with her power chair and the safety concerns this presents to others and herself. Informed resident would be evaluated by therapy and psychology at this time for her ability to use her chair safely. Further review of the medical record did not reflect any assessments or evaluations for the use of a manual wheelchair. An interview with Social Worker #82, who has been employed at the facility since 09/23/13, at 11:22 am on 05/25/23 regarding this note found she was the Social Worker who had spoken with Resident #19's friends. When asked what other residents Resident #19 run over she had stated, I know she ran over the one resident's toes. She was unable to provide any documentation of any other instances when Resident #19 ran over other residents. When asked if she could remember a time the resident had run over any other residents she could not. When asked when the incidents occurred where she ran into doorways and walls and other things in the hallways the Social Worker was unable to recall any of these incidents specifically. She was asked to provide documentation from the medical record to support this statement and at of the time of exit on 05/30/23 at 3:45 PM no further documentation to support these statements was provided. The psychologist did assess Resident #19 at the request of the facility following the incident on 10/24/23, and the following is his note related to his assessment completed on 10/28/22, Patient is an [AGE] year old female for examination due to her demonstrated inability to perform carious tasks such as safely operating her motorized wheelchair. The patient was seen in her room at the above long term care facility and the nature and extent of this examination was presented to her. She stated that she understood the purpose of this examination and voiced no objections. Patient stated that she was ready to actively participate and appeared to offer information freely. At the end patient stated that she did her best on each question and the results were presented to her shortly after the examination. Patient was administered the Neurobehavioral Cognitive Status Examination (COGNISTAT) for the purpose of today's examination. This standardized assessment instrument measures various cognitive abilities across 11 different ability domains. Regarding level of consciousness, orientation, and attention patient scored in the average range of abilities. Patient also scored in the average range of abilities on tasks comprehension. On tasks of naming and repetition, patient's scores were in the mildly impaired range, while tasks calculations and judgment were in the moderately impaired range. Lastly, tasks that required constructional abilities, memory and reasoning were in the severely impaired range. From these scores it appears that this patient lacks the basic understanding or ability to fully appreciate the impact or consequences of some of her actions or behaviors. Additionally, patient appeared quite focused on the issue of being able to operate her motorized wheelchair without any regard for the safety of those around her. Patient voiced no appreciation for her own physical deficits in relation to the safe operation of her motorized wheelchair and how she could still enjoy the events, activities, and friendships she has without this device. These and other issues will be addressed during upcoming psychotherapy sessions. Thank you for the opportunity to serve this resident. As always, please do not hesitate to contact me with and questions or concerns. The NHA, OT #172 and Social Worker #82 was asked during their interviews if this psychologist ever actually watched this resident drive her motorized wheelchair, they all three (3) said he did not he only did the cognitive portion in which he stated it appeared she did not have the ability to safely operate her motorized wheelchair. Resident #19 voiced her concerns to the psychologist about not having her independence with her motorized wheel chair and how this was going to affect her ability to participate in the events in the facility she enjoyed as evidenced by the psychologist's statement from his report which read, Patient voiced no appreciation for her own physical deficits in relation to the safe operation of her motorized wheelchair and how she could still enjoy the events, activities and friendships she has without this device. The facility claimed they transport the resident to all desired activities, but Resident #19's medical record does not support this claim. The following progress notes were written by Activities Leader (AL) #17. The first note is prior to the resident losing her ability to drive her motorized wheelchair and the second note is after. The notes read as follow: -- Note dated 10/07/22 at 9:26 am, (this was just 17 days before Resident #19 lost her privileges to operate her motorized wheelchair): (First and Last Name of Resident #19) is reviewed for a quarterly review. (First name of Resident #19) can communicate her needs and preferences to activities staff. (First name of Resident #19) transports independently via her motorized wheelchair. (First name of Resident #19) eats all her meals in her room due to Covid- 19 and social distancing. (First name of Resident #19) has a cell phone and is familiar with using it. (First name of Resident #19) enjoys sleeping in, snacking, watching television, listening to Elvis [NAME], doing her make up, her nails, spending time with pets and time outdoors when it is warm. (First name of Resident #19) enjoys using social media, especially Facebook. (First name of Resident #19) enjoys attending church services and meeting with the facility chaplain. (First name of Resident #19) enjoys playing bingo with staff assistance. (First name of Resident #19) enjoys food related activities, musical performances, parties and social events, pet therapies, seasonable activities, some games and observing some crafts. (First name of Resident #19) enjoys using her tablet to shop online. (First name of Resident #19) checks on the facility fish tank daily, she enjoys watching the fish and making sure they eaten. (First name of Resident #19) has friends at the facility and will occasionally visit their rooms and chat. (First name of Resident #19) enjoys going on outings when able. Activities staff will continue to encourage (First name of Resident #19) to participate in activities of her choosing both in and out of her room. Activities staff will continue to offer supplies for independent self-directed activities. Care plan has been reviewed and updated. -- Note dated 12/27/22 at 11:18 am (this is two (2) months after Resident #19 was no longer allowed to use her motorized wheelchair) : (First and last name of Resident #19) reviewed for a quarterly review. (First name of Resident #19) can communicate her needs and preferences to activities staff. (First name of Resident #19) transports via wheelchair with assistance from staff. (First name of Resident #19) recently lost the use of her wheelchair battery and has participated in activities far less. (First name of Resident #19) no longer visits friends throughout the facility due to her lack of independent mobility. (First name of Resident #19) will mostly stay in her room, watch television, and listen to music. (First name of Resident #19) eats all her meals in her room due to covid 19 and social distancing. (First name of Resident #19) visits the facility chaplain. (First name of Resident #19) enjoys having her hair done and nails painted. (First name of Resident #19) enjoys using her tablet to browse social media and online shop. Activities staff will continue to offer supplies for independent self-directed activities and continue to invite and encourage group activity participation. Care plan has been updated. The psychologist also indicated he would address these concerns with the resident in upcoming psychotherapy sessions. The social worker also stated she had referred the resident to the psychologist for psychotherapy sessions. A review of the record found the resident was not seen by the psychologist until 02/23/23 which was four (4) months after the initial evaluation determining she could no longer use her motorized wheelchair. During this visit the psychologist stated he was seeing the patient for depression. He again evaluated the patient's ability to safely operate her motorized wheelchair. He noted the following in regard to this evaluation: The patient responded that the current year was 2024, was unable to complete tasks of concentration, comprehension and attention. She could not recall three items after a brief interference. In summary, this patient was unable to successfully complete basic cognitive functions. Subsequently, she would likely lack the necessary cognitive and physical skills to safely operate her motorized wheelchair throughout the building, especially in areas where other elderly residents were walking with walkers etc. Also, in this note the psychologist indicated he would see the patient for psychotherapy and would see her everyone (1) to three (3) weeks for three (3) months. This was noted on 02/23/23. On 05/25/23 Social worker #82 confirmed the psychologist had not seen the resident since 02/23/23. Further review of the medical record found Resident #19 was discharged from Occupational Therapy on 10/13/22. The discharge recommendations and status on this report written by OT #172 read as follows: Discharge recommendations: PT (patient) dc (discontinued) from OT Tx(treatment) 10/13/22. PT demonstrated MOD I (Modified Independent) with power w/c (wheelchair) propulsion. COG (cognitive ) assessments at time of d/c BCAT 33 Slums 14/30 KT 18/21 showed cognitive impairment, discussed findings with social services. Social Services possibly refer for capacity assessment. Also contained in the medical record was a Comprehensive Psychiatric Evaluation which was completed the day after her discharge from OT on 10/14/22 at 2:00 PM by a Mental Health Nurse Practitioner who works with the psychologist who has completed the above-mentioned psychological evaluations. This assessment contained the following pertinent information: . Patient was a fair Historian.She was pleasant and cooperative. Orientated to person, time, situation and place. Her speech is slightly unclear with normal volume and slow rate. Her affect was reactive, congruent, and appropriate. Thought process is tangential. No psychosis noted. (first name of Resident #19) concentration is good. Psychomotor activity was noted as fidgeting. Patient is non ambulatory and uses automated wheelchair. Her recent remote memory is good. Her insight and judgement is adequate On 05/25/23 at approximately 11:15 AM when the NHA and Social Worker #82 in separate interviews, was asked what happened between 10/13/22 and 10/14/22 until 10/24/22 they both referred to the incident involving Resident #471. When asked if they had asked Resident #19 why she had run over the other residents toes they remained silent. They both again reiterated the resident was no longer capacitated so she could not use the motorized wheelchair. A review of the Resident #19's minimum data sets found the following information: -- An annual with an assessment reference date (ARD) of 7/14/22 (the assessment prior to losing the use of her motorized vehicle) found Section G00110 E.(Locomotion on unit) was coded with a 0 to indicate Resident #19 was independent with this Activity of Daily Living (ADL). And section G00110 F. Locomotion off unit was coded with a 0 to indicate the resident was independent with ADL. -- A quarterly with an ARD of 12/26/22 (The assessment following the loss of her motorized wheelchair) found Section G00110 E. (Locomotion on unit) was coded with a 3 to indicate Resident #19 was an extensive assist with this ADL and she could no longer perform it without the assistance of the staff. Section G00110 F. (Locomotion off unit) was coded with a 3 to indicate the resident was and extensive assist with this ADL and she could no longer perform it without the assistance of staff. -- A quarterly with an ARD of 03/16/23 (The most recent assessment) found Section G00110 E. (Locomotion on unit) was coded with a 3 to indicate Resident #19 was an extensive assist with this ADL and she could no longer perform it without the assistance of the staff. In an interview with the NHA on 05/25/23 at 11:08 AM the NHA stated, We made the decision based on the information we had, and we stand by that decision as being a right decision. He stated there was past incidents, but they were not documented. When asked what the incidents were, he was unable to verbally describe any other incidents other than the one which occurred on 10/24/22. When asked if there were any other incident reports involving Resident #19 and her motorized wheelchair he stated there was not. When asked if he knew how Resident #19 felt about this decision he stated, We know she is not happy about it. At the conclusion of the survey on 05/30/23 at 3:45 PM no further information was provided related to Resident #19 no longer being able to use her motorized wheelchair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, visitor interview, and resident interview the facility failed to ensure Resident #19 was free from abuse. Resident #19 had a motorized wheelchair that she had used for ten (10) years. The facility felt she was not safe to operate it anymore and took the batteries from the chair therefore disabling it. This left the feeling depressed and trapped as she had used this chair to travel throughout the facility and attend activities. She suffered psychological harm due to this. This was true for one (1) of four (4) residents reviewed for the care area of abuse. Resident identifier: #19. Facility Census: 110. Findings included: a) Resident #19 On 05/23/23 at 3:51 PM it was brought to the attention of the survey team by a concerned visitor at the facility that Resident #19 had her motorized wheelchair batteries taken away from her several months ago and the facility would not return her batteries to her nor would they allow her to use her motorized wheelchair for mobility. The visitor indicated this had been Resident #19's only form of mobility since her admission to facility which was 10 years ago. A review of Resident #19's medical record beginning at 4:00 PM on 05/23/23 found Resident #19 was admitted to the facility on [DATE] at which time she used a motorized wheelchair for mobility to assist her in getting around the facility and for getting around in her room. Further review of the medical record found on 10/24/22 there was a physician order entered into the record discontinuing the use of the motorized wheelchair for Resident#19. An interview with Resident #19 at 3:37 PM on 05/24/23 revealed the following: When asked why she was no longer able to use her motorized wheelchair Resident #19 stated, A while ago I was down by the nurses' station in my wheelchair. The Med (Medication) cart was there and in the way. There was a gentleman who had his feet out blocking my way. Another woman was behind me and kept pushing on my wheelchair. I was afraid she was going to break my chair by pushing on it. I asked him to move his feet three times and he did not, so I ran over them. I did not have any other choice because the woman kept pushing on my chair and I did not want her to break my chair. Resident #19 continued to state that later that evening they took her battery and had not given it back since. When asked how losing her ability to use her motorized wheelchair made her feel she stated, I feel like I am trapped and have been in jail. The resident said, Nine (9) months is a long enough punishment for what I did don't you think. When it first happened, I was sad and now I am just angry because I cannot go like I was able to then. She further stated, They told me they would take me to all the activities, but they don't, there is not enough staff to get me there. She also stated, Physical Therapy asked me to give them my chair so someone else could use it, but it's my chair and I want to use it. The facility presented an incident report dated 10/22/22 for Resident #471, this incident indicated Resident #19 ran over Resident #471's feet with her motorized wheelchair. The incident report indicated Resident #19 was not paying attention while driving her motorized wheelchair as the cause of this accident. However, Resident #19's account of the incident does not indicate she was not paying attention. Her recount of the incident demonstrates there were several extenuating circumstances such as the medication cart being parked in the way, the resident being asked to move his feet and did not, and the other female resident who was continually pushing on the back of her wheelchair. The resident felt she made the only decision available to her because no staff was present to assist with eliminating any of the factors inhibiting her ability to pass by the area safely. The following pertinent information was obtained from Resident #471's medical record: A nurses note dated 10/22/22 at 7:17 PM which read as follows, This nurse informed by staff that resident of (room Number of Resident #19) ran over (First and Last Name of Resident #471) feet with motorized wheelchair. Resident stated both feet when asked by this nurse. Upon Assessment. No Redness, bruising, or swelling noted. Right Hallux began bleeding during assessment. This toe already had a band aid treatment in place. Right Hallux cleaned and new Band-Aid applied. Resident currently propelling self with legs down the hallway in wheelchair. Denies pain at present. Physician and Wife/POA notified. Additional note in Resident #471's record dated 10/23/22 at 6:28 PM read as follows, Results from X-ray of feet received. No acute fracture or dislocation. Findings consistent with gout. Resident #471's diagnosis included, Vascular Dementia with behavioral disturbance, lack of coordination, and anxiety disorder. On 05/24/23 at 10:33 am an interview with Occupational Therapist (OT) #172, confirmed Resident #19 was no longer allowed to use her motorized wheelchair. He stated they did evaluations on all residents who have a motorized wheelchair and the first thing they look at is decision making capacity. He stated if a resident loses capacity, they no longer can make right decisions. He stated there was also one (1) incident where the resident ran over someone's toes, and it coincided with the resident's annual assessment. He stated her scores on her cognitive tests had decreased so he referred her to the psychologist to evaluate her capacity. The Mental Health Nurse Practitioner evaluated the resident the following day on 10/14/22 and noted no issues with the resident using her motorized wheelchair nor any cognitive issues which would impair Resident #19's ability to make medical decisions. When asked if the reason Resident #19 was no longer allowed to use her motorized wheelchair was because she lost capacity to make medical decisions? OT #172 stated, Yes that is the main reason. Resident #19's medical record contained a Physician's Determination of Capacity indicating Resident #19 lacked capacity to make medical decisions. This capacity statement was dated 11/07/22. This was completed two (2) weeks after Resident #19's batteries were taken from her, and only three (3) weeks after the evaluation by the Mental Health Nurse Practitioner which noted no concerns related Resident #19's decision making ability. OT #172 was asked to provide copies of the cognitive tests he performed on Resident #19 which he spoke of during his interview. A review of these test found the following information (Please note all tests were performed prior to the incident which took place on 10/24/22): - Brief Interview of Mental Status (BIMS) : Score 13 of 15. This score indicates Intact Cognitive response. (Please note a review of the OT discharge summary for the dates of service from 09/28/22 - 10/13/22 indicated Resident #19's baseline score on the BIMS was 13 of 15 on 09/28/22 (which was one (1) month prior to Resident #19 being told she could no longer use her motorized wheelchair.) - Brief Cognitive Assessment Tool (BCAT): Score 33 of 50. This score indicates mild dementia. (This score was noted on 10/13/22) - St. Louis University Mental Status Exam (SLUMS): 14 of 30. This score indicates dementia. (This score was also noted on 10/13/22). During an interview with the Nursing Home Administrator (NHA) at 4:05 PM on 05/24/23 he stated, If a resident does not have decision making ability (Capacity to make medical decisions) they are not able to use a powered wheelchair because they cannot make safe decisions. That is how it has always been in this building; I just went along with it. I think there are other instances of her being unsafe I'll bring you the documentation. At the conclusion of the survey on 05/30/23 at 3:45 PM the NHA had not provided any further documentation to confirm Resident #19 had any other instances in her motorized wheelchair which made her unsafe to operate it other than the incident on 10/24/22. A further review of the medical record was completed on 05/24/23 and the following information was found: a nursing progress note dated 10/25/22 at 3:45 PM which read as follows, Spoke with friends of resident at residents request regarding her wheelchair that is motorized not being authorized for her use at this time due to safety concerns. (First and last name of Two (2) friends) contacted and returned the phone calls with social worker. Explained situation of resident running over other residents and bumping into doorways and walls and things in hallways and room with her power chair and the safety concerns this presents to others and herself. Informed resident would be evaluated by therapy and psychology at this time for her ability to use her chair safely. Further review of the medical record did not reflect any assessments or evaluations for the use of a manual wheelchair. An interview with Social Worker #82, who has been employed at the facility since 09/23/13, at 11:22 am on 05/25/23 regarding this note found she was the Social Worker who had spoken with Resident #19's friends. When asked what other residents Resident #19 run over she had stated, I know she ran over the one resident's toes. She was unable to provide any documentation of any other instances when Resident #19 ran over other residents. When asked if she could remember a time the resident had run over any other residents she could not. When asked when the incidents occurred where she ran into doorways and walls and other things in the hallways the Social Worker was unable to recall any of these incidents specifically. She was asked to provide documentation from the medical record to support this statement and at of the time of exit on 05/30/23 at 3:45 PM no further documentation to support these statements was provided. The psychologist did assess Resident #19 at the request of the facility following the incident on 10/24/23, and the following is his note related to his assessment completed on 10/28/22, Patient is an [AGE] year old female for examination due to her demonstrated inability to perform carious tasks such as safely operating her motorized wheelchair. The patient was seen in her room at the above long term care facility and the nature and extent of this examination was presented to her. She stated that she understood the purpose of this examination and voiced no objections. Patient stated that she was ready to actively participate and appeared to offer information freely. At the end patient stated that she did her best on each question and the results were presented to her shortly after the examination. Patient was administered the Neurobehavioral Cognitive Status Examination (COGNISTAT) for the purpose of today's examination. This standardized assessment instrument measures various cognitive abilities across 11 different ability domains. Regarding level of consciousness, orientation, and attention patient scored in the average range of abilities. Patient also scored in the average range of abilities on tasks comprehension. On tasks of naming and repetition, patient's scores were in the mildly impaired range, while tasks calculations and judgment were in the moderately impaired range. Lastly, tasks that required constructional abilities, memory and reasoning were in the severely impaired range. From these scores it appears that this patient lacks the basic understanding or ability to fully appreciate the impact or consequences of some of her actions or behaviors. Additionally, patient appeared quite focused on the issue of being able to operate her motorized wheelchair without any regard for the safety of those around her. Patient voiced no appreciation for her own physical deficits in relation to the safe operation of her motorized wheelchair and how she could still enjoy the events, activities, and friendships she has without this device. These and other issues will be addressed during upcoming psychotherapy sessions. Thank you for the opportunity to serve this resident. As always, please do not hesitate to contact me with and questions or concerns. The NHA, OT #172 and Social Worker #82 was asked during their interviews if this psychologist ever actually watched this resident drive her motorized wheelchair, they all three (3) said he did not he only did the cognitive portion in which he stated it appeared she did not have the ability to safely operate her motorized wheelchair. Resident #19 voiced her concerns to the psychologist about not having her independence with her motorized wheel chair and how this was going to affect her ability to participate in the events in the facility she enjoyed as evidenced by the psychologist's statement from his report which read, Patient voiced no appreciation for her own physical deficits in relation to the safe operation of her motorized wheelchair and how she could still enjoy the events, activities and friendships she has without this device. The facility claimed they transport the resident to all desired activities, but Resident #19's medical record does not support this claim. The following progress notes were written by Activities Leader (AL) #17. The first note is prior to the resident losing her ability to drive her motorized wheelchair and the second note is after. The notes read as follow: -- Note dated 10/07/22 at 9:26 am, (this was just 17 days before Resident #19 lost her privileges to operate her motorized wheelchair): (First and Last Name of Resident #19) is reviewed for a quarterly review. (First name of Resident #19) can communicate her needs and preferences to activities staff. (First name of Resident #19) transports independently via her motorized wheelchair. (First name of Resident #19) eats all her meals in her room due to Covid- 19 and social distancing. (First name of Resident #19) has a cell phone and is familiar with using it. (First name of Resident #19) enjoys sleeping in, snacking, watching television, listening to Elvis [NAME], doing her make up, her nails, spending time with pets and time outdoors when it is warm. (First name of Resident #19) enjoys using social media, especially Facebook. (First name of Resident #19) enjoys attending church services and meeting with the facility chaplain. (First name of Resident #19) enjoys playing bingo with staff assistance. (First name of Resident #19) enjoys food related activities, musical performances, parties and social events, pet therapies, seasonable activities, some games and observing some crafts. (First name of Resident #19) enjoys using her tablet to shop online. (First name of Resident #19) checks on the facility fish tank daily, she enjoys watching the fish and making sure they eaten. (First name of Resident #19) has friends at the facility and will occasionally visit their rooms and chat. (First name of Resident #19) enjoys going on outings when able. Activities staff will continue to encourage (First name of Resident #19) to participate in activities of her choosing both in and out of her room. Activities staff will continue to offer supplies for independent self-directed activities. Care plan has been reviewed and updated. -- Note dated 12/27/22 at 11:18 am (this is two (2) months after Resident #19 was no longer allowed to use her motorized wheelchair) : (First and last name of Resident #19) reviewed for a quarterly review. (First name of Resident #19) can communicate her needs and preferences to activities staff. (First name of Resident #19) transports via wheelchair with assistance from staff. (First name of Resident #19) recently lost the use of her wheelchair battery and has participated in activities far less. (First name of Resident #19) no longer visits friends throughout the facility due to her lack of independent mobility. (First name of Resident #19) will mostly stay in her room, watch television, and listen to music. (First name of Resident #19) eats all her meals in her room due to covid 19 and social distancing. (First name of Resident #19) visits the facility chaplain. (First name of Resident #19) enjoys having her hair done and nails painted. (First name of Resident #19) enjoys using her tablet to browse social media and online shop. Activities staff will continue to offer supplies for independent self-directed activities and continue to invite and encourage group activity participation. Care plan has been updated. The psychologist also indicated he would address these concerns with the resident in upcoming psychotherapy sessions. The social worker also stated she had referred the resident to the psychologist for psychotherapy sessions. A review of the record found the resident was not seen by the psychologist until 02/23/23 which was four (4) months after the initial evaluation determining she could no longer use her motorized wheelchair. During this visit the psychologist stated he was seeing the patient for depression. He again evaluated the patient's ability to safely operate her motorized wheelchair. He noted the following in regard to this evaluation: The patient responded that the current year was 2024, was unable to complete tasks of concentration, comprehension and attention. She could not recall three items after a brief interference. In summary, this patient was unable to successfully complete basic cognitive functions. Subsequently, she would likely lack the necessary cognitive and physical skills to safely operate her motorized wheelchair throughout the building, especially in areas where other elderly residents were walking with walkers etc. Also, in this note the psychologist indicated he would see the patient for psychotherapy and would see her everyone (1) to three (3) weeks for three (3) months. This was noted on 02/23/23. On 05/25/23 Social worker #82 confirmed the psychologist had not seen the resident since 02/23/23. Further review of the medical record found Resident #19 was discharged from Occupational Therapy on 10/13/22. The discharge recommendations and status on this report written by OT #172 read as follows: Discharge recommendations: PT (patient) dc (discontinued) from OT Tx(treatment) 10/13/22. PT demonstrated MOD I (Modified Independent) with power w/c (wheelchair) propulsion. COG (cognitive ) assessments at time of d/c BCAT 33 Slums 14/30 KT 18/21 showed cognitive impairment, discussed findings with social services. Social Services possibly refer for capacity assessment. Also contained in the medical record was a Comprehensive Psychiatric Evaluation which was completed the day after her discharge from OT on 10/14/22 at 2:00 PM by a Mental Health Nurse Practitioner who works with the psychologist who has completed the above-mentioned psychological evaluations. This assessment contained the following pertinent information: . Patient was a fair Historian.She was pleasant and cooperative. Orientated to person, time, situation and place. Her speech is slightly unclear with normal volume and slow rate. Her affect was reactive, congruent, and appropriate. Thought process is tangential. No psychosis noted. (first name of Resident #19) concentration is good. Psychomotor activity was noted as fidgeting. Patient is non ambulatory and uses automated wheelchair. Her recent remote memory is good. Her insight and judgement is adequate On 05/25/23 at approximately 11:15 AM when the NHA and Social Worker #82 in separate interviews, was asked what happened between 10/13/22 and 10/14/22 until 10/24/22 they both referred to the incident involving Resident #471. When asked if they had asked Resident #19 why she had run over the other residents toes they remained silent. They both again reiterated the resident was no longer capacitated so she could not use the motorized wheelchair. A review of the Resident #19's minimum data sets found the following information: -- An annual with an assessment reference date (ARD) of 7/14/22 (the assessment prior to losing the use of her motorized vehicle) found Section G00110 E.(Locomotion on unit) was coded with a 0 to indicate Resident #19 was independent with this Activity of Daily Living (ADL). And section G00110 F. Locomotion off unit was coded with a 0 to indicate the resident was independent with ADL. -- A quarterly with an ARD of 12/26/22 (The assessment following the loss of her motorized wheelchair) found Section G00110 E. (Locomotion on unit) was coded with a 3 to indicate Resident #19 was an extensive assist with this ADL and she could no longer perform it without the assistance of the staff. Section G00110 F. (Locomotion off unit) was coded with a 3 to indicate the resident was and extensive assist with this ADL and she could no longer perform it without the assistance of staff. -- A quarterly with an ARD of 03/16/23 (The most recent assessment) found Section G00110 E. (Locomotion on unit) was coded with a 3 to indicate Resident #19 was an extensive assist with this ADL and she could no longer perform it without the assistance of the staff. In an interview with the NHA on 05/25/23 at 11:08 AM the NHA stated, We made the decision based on the information we had, and we stand by that decision as being a right decision. He stated there was past incidents, but they were not documented. When asked what the incidents were, he was unable to verbally describe any other incidents other than the one which occurred on 10/24/22. When asked if there were any other incident reports involving Resident #19 and her motorized wheelchair he stated there was not. When asked if he knew how Resident #19 felt about this decision he stated, We know she is not happy about it. At the conclusion of the survey on 05/30/23 at 3:45 PM no further information was provided related to Resident #19 no longer being able to use her motorized wheelchair.