Customized Wheelchair 

Goal 
To provide a wheelchair specifically manufactured to meet the special medical, physical, and psychosocial needs of residents who cannot independently maintain proper body alignment. 

Policy 
It is the policy of the facility to conduct interdisciplinary assessments, assess resident needs, and deliver appropriate customized wheelchairs and related services to residents. 

Procedure 

Interdisciplinary Team (IDT) Assessment: 

• Members of IDT: 

Resident’s attending physician. 

Physician board certified or board eligible in orthopedics or physical medicine. 

Registered Physical Therapist (PT) or Registered Occupational Therapist (OT). 

Licensed Nurse. 

• Purpose of IDT: 

To ensure appropriate assessment of the resident's need for a customized wheelchair. 

To ensure appropriate design of the required customized wheelchair. 

To provide appropriate instructions to the facility on the use and maintenance of the customized wheelchair. 

• IDT Assessment Requirements: 

Physical examination by the attending physician. 

Orthopedic or physiatric examination by an orthopedist or physiatrist. 

Rehabilitative examination by a Physical Therapist or Occupational Therapist. 

Documentation as part of the resident’s medical record. 

Assessment performed within 3 months prior to the date of the request for a customized wheelchair. 

Assessment incorporated into the resident’s care plan. 

Facilitator: 

• Role: 

The facilitator may be the Attending Physician, Registered Physical Therapist, Registered Occupational Therapist, or Registered Nurse. 

• Responsibilities: 

Attend and participate in assessments performed by the Orthopedist or Physiatrist and any assessments performed by the Physical or Occupational Therapist. 

Ensure all required assessments are performed. 

Ensure required documentation is submitted to the medical equipment provider. 

Ensure the 24-hour positioning plan is developed by the professional staff of the facility. 

Ensure the positioning plan is incorporated into the resident’s care plan as per the attending physician's order. 

Ensure nursing staff receive appropriate training in the proper use of the customized wheelchair and in implementing the 24-hour positioning plan. 

Monitor: 

• Role: 

A member of the professional nursing staff. 

• Responsibilities: 

Monitor the resident’s physical adaptation to the customized wheelchair, including monitoring for decubitus or any other adverse health effects. 

Monitor the compliance of the facility’s nursing and direct care staff with the 24-hour positioning plan. 

Indicated by name on the 24-hour positioning plan. 

Inservice Training: 

• Responsibilities: 

The Durable Medical Equipment Provider will help teach and train the recipient and nursing facility on the proper use and care of the customized wheelchair upon delivery. 

The monitor will ensure nursing staff receive appropriate training in the proper use and care of the customized wheelchair. 

Documentation of all inservice training must be maintained. 

Twenty-four (24) Positioning Plan: 

• Requirements: 

Must be in place on the date of delivery of the customized wheelchair. 

Developed by the facility's professional staff (nursing, PT, OT) with the attending physician. 

Monitored by the appointed monitor. 

Incorporated into the resident care plan. 

Ongoing Monitoring Documentation: 

• Monthly Note: 

Completed by a member of the professional nursing staff (RN or LPN). 

Address any health issues related to the use of a customized wheelchair, compliance with instructions on use, and the 24-hour positioning plan. 

Assess the need for any modifications to the wheelchair or positioning plan. 

• Quarterly Note: 

Completed by a member of the rehabilitation staff (PT or OT). 

Address any health issues related to the customized wheelchair, facility compliance, and the appropriateness of the wheelchair. 

Consider and make recommendations for additional rehabilitation services if indicated. 

• Annual Review: 

Conducted by an interdisciplinary team, including the resident’s attending physician, a registered PT or OT, and a representative of the professional nursing staff. 

Assess the resident and determine if the customized wheelchair continues to meet their needs. 

Maintain documentation of all assessments, the plan of care, and progress notes in the resident’s permanent record. 

Documentation Requirements: 

• Maintain all medical records required by the customized wheelchair policy, including assessments, care plans, 24-hour positioning plans, and monitoring documentation, in the resident’s permanent record. 

• Ensure all records are available for inspection by authorized department personnel. 

Forms: 

• Monthly Note: 

Resident Name: _______________________________ 

Physician: _______________________________ 

Health issues related to use of customized wheelchair: _______________________________ 

Nursing and direct care staff compliance with instructions on use: _______________________________ 

Compliance with 24-hour positioning plan: _______________________________ 

Modifications needed: _______________________________ 

Licensed Nurse Signature: _______________________________ Date: __________ 

• Quarterly Rehabilitation Reviews: 

Resident Name: _______________________________ 

Physician: _______________________________ 

Health issues related to use of customized wheelchair: _______________________________ 

Facility compliance with instructions on use: _______________________________ 

Compliance with 24-hour positioning plan: _______________________________ 

Appropriateness of the wheelchair: _______________________________ 

Recommendations: _______________________________ 

PT/OT Signature: _______________________________ Date: __________ 

• Annual Review: 

Reassessment of Resident: _______________________________ 

Design of wheelchair appropriateness: _______________________________ 

Physician Signature: _______________________________ Date: __________ 

PT/OT Signature: _______________________________ Date: __________ 

Licensed Nurse Signature: _______________________________ Date: __________ 

• 24-Hour Positioning Plan (Sample): 

Resident Name: _______________________________ 

Date Implemented: _______________________________ 

Monitor: _______________________________ 

Daily schedule outlining specific positioning and activities. 

References: 

• Centers for Medicare & Medicaid Services (CMS), State Operations Manual (SOM) 

• Requirements of Participation for Nursing Homes, CMS