Federal Regulations Review

The federal regulations that GROW Coalition believe support the GROW coalition goals are offered for consideration. The focus will be the concept of person-centered care, the utilization of seating choices other than wheelchairs when the resident is stationery and the use of a wheelchair for total locomotion when the resident could maintain walking to some extent.

Appendix P, Part IV
Psychosocial Outcome Guide

Following is a review of the negative psychosocial outcomes from use of wheelchairs as a seating device and a mobility device when the resident can walk. The review looks at the relationship between a wide variety of the regulations and the psychosocial outcome guide.

F154
483.10(d)(2)
Right to be fully informed in advance about care and treatment.....

An assessment and a process by which residents would be fully informed about their need for seating options would include a variety of seating options throughout the day depending on the resident activity. The resident also needs to be informed of the value of maintenance of mobility as well as the potential for negative outcomes from overuse of wheelchairs.

F157
483.10(b)(11)
Notification of changes

A change in seating options and/or mobility would be included in this notification of change section.

F174
483.10(1)
Right to retain and use personal property including some furnishings.....

The updated guideline in this section speaks to encouraging residents to bring personal possessions into the facility. The use of seating options that the resident used prior to admission to the facility works toward meeting the intent of this section.

F207
483.12(c)(1)
Equal access to quality care

When a resident seating option assessment supports the use of chairs other than a wheelchair, the use of those chairs would need to be assured during a transfer regardless of the resident ‘s source of payment source.

F222
483.13(a)
Right to be free from physical restraints

Placing a resident in a wheelchair when they are unable to move it due to physical or cognitive deficits makes puts the resident in a restrained situation.

F241
483.13(a)
Dignity

In our culture the use of a wheelchair denotes disability. Reaction to individuals in wheelchairs is often strident or strained at the best. Use of wheelchairs for reasons other than mobility put the resident in a situation where their dignity is neither enhanced or maintained and his/her individuality is not respected.

F242
483.15(b)(3)
Right to choose aspects of his/her life in the facility that are significant to the resident.

Choice of seating is a major part of each person’s life. Many hours and dollars are spent on selecting “just the right chair” for resting and “just the right” chair for the kitchen table. That choice of seating decision needs to stay with the person when they become a resident. Often a long-term care facility issue a bed and a wheelchair on admission. This tells the resident and his/her family that the wheel chair is the accepted seating device, period. Continued use of the wheelchairs with a majority of residents sets a standard for the facility practices. A case could be made for de facto coercion.

F246
483.15(e)
Accommodation of needs
Seating option choices, since they are individualized, fit very well into meeting this section.

F248
483..15(f)(1)
Activities
An ongoing program of activities....
Utilization of rocking chairs would be an example of person-centered care focused on activity and seating preference combined . Where residents sit during a stationary activity should be based on the resident’s history of seating and comfort. Walking to activities rather than wheeling can be a very logical approach to maximizing mobility.

F252
483.15(h)91)
Right to a .......comfortable and homelike environment, allowing the resident to use his or her personal belongings....

This section utilizes the word “comfortable”. Individualized seating options based on the residents comfort and choice lead to a comfortable and familiar environment for the resident. This section speaks to de-emphasizing the institutional character of the setting. Wheelchairs as non-mobility seating ptions fly in the face of the tenant of this section. Wheelchairs are nstitutional in nature and send a very un-homelike image.

F272

483.20
Assessments
A seating option along with a mobility assessment need to be part of this comprehensive, accurate, standardized reproducible assessment that will identify the resident’s functional capacity. If a person cannot move a wheelchair for physical or cognitive reasons, this does not negate the need to assess non-mobility seating ption. The mobility assessment will provide information that will keep the resident mobile to the maximum extent possible.

(ii) Customary Routine
Assessing where the resident sat when he/she was non-mobile is a part of this requirement. as well as the resident’s mobility as part of their customary  routine.

(iii) Cognitive Patterns
This is where the resident’s cognitive ability would be determined. This factor would be then coupled with the remainder of the assessments in F272 when looking at non-mobility seating selections. and mobility interventions.

vi) Mood and Behavior, and(vii)Psychological well-being

It has been reported that individuals in wheelchairs state that the occurrence of others engaging them in conversation was diminished due to the presence of the wheelchair. The feeling of isolation coupled with reduced self-esteem due to the use of a wheelchair could be supported as a reason for some of the actions addressed in these assessment areas:

(viii) Physical Functioning
This is the section that captures the use of the wheelchair for mobility. Special attention needs to be paid to those residents with “Other person wheeled” as an answer. This could indicate that the resident remaining in the wheelchair when non-mobile would also be the results of the action of someone other than the resident.

Assessing if the resident’s inability to transfer is due to numbness in arms or legs due to pressure on pressure points is vital.

(xii) Skin Conditions
The seats of wheelchairs hold moisture. This assessment section should consider the role the constant use of a wheelchair has on the skin condition of the resident.

(xv) Special Treatments - Restorative Care
Assessment of a resident’s restorative actions needs to take into consideration the deleterious effects of non-mobility use of wheelchairs on ambulation, transfer and communication. Restorative programs for transferring and walking are strongly supported by the GROW Coalition approach to care.

F280
483.10(d)(3)
Right to participate in care planning

Seating option and mobility choices must be part of this process, based on the resident’s seating and mobility history and assessment. With a social model of person-centered care use of seating options must be supported by resident choice. In the case of a resident with cognitive loss work with the family and a visit to their home will assist the care planning process by providing seating option and mobility history.

F309

483.25
Right to receive care to attain or maintain their highest practicable, physical, mental, and psychosocial well-being. The use of wheelchairs for non-mobility situations does not support this section. The wheelchair reduces physical wellness by increasing the likelihood of reduced ambulation, increased pressure point involvement and increased risk for skin breakdown. It impacts the mental and psychosocial well-being due to the cultural belief that people in wheelchairs are less than whole, therefore they experience reduced individualized interactions in these areas.

Additionally wheeling residents who could walk does not support reaching the highest practicable levels of well-being.

F314
483.25(c)
Right to be free from pressure sores

To restate: constant use of wheelchairs works at cross purposes to this section.

Additionally, skin tears, bruises and scrapes often occur when residents in
wheelchairs for extended periods of time try to move and bump or hit their
extremities on the metal portions of the wheelchair thus increasing not reducing injury.

F317
Right to maintain the fullest range of motion

Confinement to a wheelchair often reduces the resident's movement, especially of their hip joints. A contracture of their hip joints impedes their mobility and their quality of life.

F319
483.25(f)(1)
Right to receive appropriate treatment for mental or psychosocial adjustment difficultyand,
F320

483.25 (f)(2)
No reduction in social interaction, withdrawal, anger.......

Coming into a facility and being placed in a wheelchair for mobility and non-mobility use can very likely increase the likelihood that the resident will experience adjustment difficultly. Giving up their home, their freedom, their independence and their seating choice often results in any and all of the situations mentioned in these two sections. This coupled with the cultural approach to residents in wheelchairs could very easily be the reason problems arise as mentioned in F320.

F324
483.25(h)(2)

Receive adequate supervision and assistive devices to prevent accidents

The wheels on wheelchairs increase their accident potential de facto. Add to that the high percentage of cognitive loss in the resident population and the risk increases. Often these residents have the ability to unlock the chair which adds to the potential for injury. Many falls are from wheelchairs when esidents attempt to stand and the wheels are not locked, their feet are asleep, their hips don’t move appropriately, and their ability to understand what is happening is diminished so they cannot compensate. Utilization of wheelchairs as non-mobility seating options are certainly not assistive devices and in many cases prove to be detrimental to the resident’s potential for an accident.

F326
483.25(i)(2)
Assure resident maintains acceptable parameters of nutrition......

Eating is a social as well as a nutritional activity. If the resident is uncomfortable sitting in a wheelchair or has trouble reaching the table because the wheelchair construction does not allow the proper distance between the resident and their food the result often is lack of desire to eat. The seating in a dining area needs to be comfortable and such that it will encourage adequate socialization and nutritional intake.

F327
483.25(j)
Each resident must have sufficient fluid intake......

When wheelchairs are used for non-mobile seating options, they are almost always not near a table. This becomes significant when the goal is to encourage fluid intake but there is no place for the resident to place the glass between swallows or when they are finished. It is difficult to manage the drinking situation when in a wheelchair. This often reduces the resident’s desire to drink at all.

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