Prohealth Home Care, Inc.

“Based on observation, interview and record review, the hospice (a specialized, holistic, and compassionate care program for people with a terminal illness) agency failed to ensure medication safety for one of fifteen sampled patients (Patient 2) when on 4/21/26 Patient 2 had medications that were not verified with the skilled nursing facility (SNF: a licensed, 24-hour inpatient health facility that provides medical care and nursing services) staff during the comprehensive review visit. This failure had the potential to result in unsafe medication use and decreased well-being for Patient 2. Findings: During a concurrent observation, interview and record review, on 4/21/26 at 11:25 AM, with Registered Nurse (RN) 3 and Licensed Nurse (LN) 1, Patient 2’s medications were reviewed and compared to Patient 2’s current Hospice Plan of Care (POC - a personalized, comprehensive roadmap developed to manage a terminally ill patient’s physical, emotional, and spiritual needs) medication profile. The following differences were noted when the POC medications list was compared to the medications being given to Patient 2 at the SNF:1. Sertraline (prescription medication used to treat depression) HCL (hydrochloride) 25 mg (mg -milligram a unit of measure equal to 1/1000 of a gram) give 1 tablet by mouth one time a day.-Patient 2’s POC dated 2/20/26, indicated: Sertraline HCl 50 mg Tab(s) (tablet) oral 1 tablet daily.2. Divalproex (a prescription medication used to treat seizures, and manic episodes) DR (Delayed Release) 125 mg Cap (capsule), give 2 capsules by mouth twice daily.-Patient 2’s POC dated 2/20/26, indicated: Divalproex Sodium 125 mg, 4 capsules twice a day.In addition, the medication: Hyoscyamine Sulfate (a prescription medication used to treat conditions requiring muscle relaxation or reduced secretions) 0.125 mg oral tablet, ordered to give to Patient 2 every 4 hours as needed, was not available in the facility for use. LN 1 stated that Patient 2 had been on the current doses of these medications in the SNF since 3/9/26. Additionally, LN 1 confirmed the medication Hyoscyamine Sulfate was not available in the facility for Patient 2’s use. RN 3 confirmed the above medication discrepancies and stated that Patient 2’s POC medication profile should match the medication that was being administered at the SNF. RN 3 stated it was expected with each comprehensive visit that the medications were checked to make sure the medications being given to the patients matched the POC. RN 3 further stated each nurse visit was considered a comprehensive visit and they should be looking at each medication for accuracy. RN 3 explained it was important to observe each medication to make sure the patients were getting the right medication and the right dose and that each medication was available for use. RN 3 further explained the risk to the patient was not being properly monitored for side effects of medication. RN 3 stated hyoscyamine not being available could put Resident 2 at risk for choking on excessive secretions (overproduction of fluids such as phlegm or saliva). During an interview on 4/22/26 at 12:46 PM, with the Director of Patient Care Services (DPSC), the DPSC stated it was expected that each patient’s medication profile on their POC be updated with every visit. The DPCS further stated that it included looking at each medication bottle and patient medication profile on the POC to make sure they matched. The DPCS explained it was important to check the medications to prevent overdose of medication or an allergic reaction. The DPCS added the nurses were expected to make sure each medication ordered was available for use. The DPCS stated the risk to the patient was a delay in care if a medication was needed and was not available. The DPCS further stated the POC was a live document (allows real-time, editing and collaboration by multiple users at the same time) and should always be updated with any changes. A review of a facility policy and procedure titled, “Medication Management,” revised November 2024, indicated, “..Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications…3. A drug regimen review will be performed at the time of initial and comprehensive assessment…4. During subsequent hospice visits, the medication profile will be used…A. Using the medication profile to evaluate the use of the drugs in the home setting. C. Using the medication profile as a communication tool for other clinicians involved in care…Deviations in taking medications as ordered will be documented in the clinical notes, and the physician (or other licensed practitioner) will be notified…9. The medication profile…will be available to all clinicians providing care…11. A complete list of the patient’s medications will be communicated to the next provider of service…””

“Based on interview and record review the facility failed to ensure the Plan of Care (POC - a personalized, comprehensive roadmap developed by an interdisciplinary team (IDG) to manage a terminally ill patient’s physical, emotional, and spiritual needs) included the scope and frequency of visits (how many days per week a nurse, aide, social worker, etc. will visit the patient) necessary to meet the needs of two of fifteen sampled patients (Patient 3 and Patient 4) when it was verified that the POC for the certification/benefit period (a designated time frame during which a physician certifies a patient has a terminal illness) 3/21/2026 to 5/19/2026, did not include the scope or frequency of visits for Patient 3, and the POC for the certification period/benefit period, 3/18/26 to 5/16/26, did not include the scope or frequency of visits for Patient 4. This failure had the potential to negatively impact Patient 3 and Patient 4 by not meeting their physical, emotional, and spiritual needs. Findings:A review of Patient 3’s POC dated 3/21/26, indicated, Patient 3 was admitted to the hospice agency with diagnoses that included, senile degeneration of brain (an age-related, progressive decline in cognitive function characterized by brain shrinking, memory loss, and reduced mental ability) and dementia (a progressive decline in mental ability severe enough to interfere with daily life, caused by physical brain damage). Further review of the POC under the section, “FREQUENCIES,” indicated, “Completed or Discontinued.” Additionally, the frequency visits listed for “RN/LVN” (RN-Registered Nurse, LVN -Licensed Vocational Nurse), indicated the visits were three times per week and ended 3/20/26.A review of Patient 3’s electronic medical record (EHR - a digital, computer-stored version of a patient’s paper chart within a specific clinic or hospital, containing medical history, diagnoses, medications, and treatment plans) visit calendar schedule for the benefit period 3/21/26 through 5/19/26 indicated that Patient 3 continued to receive skilled nursing visits (specialized, intermittent assessments and interventions performed by a RN or LVN to manage terminal symptoms, pain, and provide comfort care at home or in a facility) on: 3/23/26, 3/28/26, 3/30/26, 4/1/26, 4/3/26, 4/6/26, 4/8/26, 4/10/26, 4/12/26, 4/13/26, 4/15/26, 4/16/26, 4/17/26 and 4/20/26.A review of Patient 3’s EHR document titled, “IDG MEETING REVIEW,” (IDG - is a dedicated team of professionals—including a physician, nurse, social worker, and counselor—designated by a hospice to provide comprehensive, holistic care to patients and families) dated 3/31/26, for certification/benefit period 3/21/26 through 5/19/26, under the section “FREQUENCIES,” was blank. Additionally, a review of Patient 3’s, “IDG MEETING REVIEW,” dated 4/14/26 for the same certification period, indicated, “…Accepting 2x/week [two times a week] and HHA declines [hospice home health aide]…” A further review of the section, “FREQUENCIES,” was blank. The IDG meeting review was not signed by a physician.During a concurrent interview and record review on 4/21/26 at 3:08 PM, with the Administrator (ADM), Patient 3’s POC and IDG meetings for the certification/benefit period 3/21/26 to 5/19/26 were reviewed. The ADM confirmed the visit frequencies were not updated for the certification period. The ADM stated that sometimes the frequency of visits could be added during the IDG meetings and signed by the physician. The ADM confirmed that the frequency of visits expired on 3/20/26 and the section for frequencies on the IDG meetings dated 3/31/26 and 4/14/26 were left blank. The ADM stated that the frequency visits order should be completed by the RN case manager for scope and frequency of visits and signed by the physician. The ADM confirmed the visits continued without a physicians order for the scope and frequency of visits.During an interview on 4/22/26 at 12:46 PM with the Director of Patient Care Services (DPCS), the DPCS stated her expectation for the frequency of visits would be in the form of a physicians order obtained by the RN case manager each certification/benefit period. The DPCS stated that the risk of the patients not having a frequency order was that the patient could have a missed visit, may not be seen as frequently as needed creating a delay of care and jeopardizing their safety.A review of Patient 4’s POC dated 3/18/26 indicated that Patient 4 was admitted to the hospice agency with diagnoses that included breast cancer. Further review of the POC under the section, “FREQUENCIES,” indicated, “…Active…MSW [social worker]…1 X [times] month for 3 months…starting 3/18/26…End Date…5/16/2026…” Under the section “Completed or Discontinued” the frequency visits listed for “RN/LVN” indicated the visits were 7 times per week and ended 3/20/26 and the frequency visits listed for “HHA [home health aide]” indicated the visits were 2 times per week and ended 3/14/26.A review of Patient 4’s electronic medical record (on 4/21/26) visit calendar schedule for the benefit period 3/18/26 through 5/16/26 indicated that Patient 4 continued to receive skilled nursing visits (specialized, intermittent assessments and interventions performed by an RN or LVN to manage terminal symptoms, pain, and provide comfort care at home or in a facility) seven days a week starting 3/18/26 through the review date, and received HHA visits two times a week starting 3/18/26 through the review date. During a concurrent interview and record review with the ADM on 4/21/26 at 3:49 PM, of Patient 4’s POC and visit calendar, the ADM stated that the nurses were still learning how to enter the frequency of visits into the POC. The ADM confirmed that Patient 4 was currently receiving HHA visits two times a week, nursing visits seven days a week, and MSW visits one time per month. The ADM confirmed Patient 4’s current POC did not include frequency visits for nursing or the HHA. The ADM stated the importance of an accurate POC was to ensure Patient 4’s individual needs were met and individualized to keep her safe.A review of the facility policy and procedure (P&P) titled, “THE PLAN OF CARE,” revised November 2024, indicated, “…A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process…4. The plan of care will identify the patient’s needs and services to meet those needs…It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs…6. The plan of care will be provided to both and attending physician and the hospice Medical Director for approval of verbal orders and certification…12. The written plan of care will contain…Frequency and type of services…Physician (or other licensed practitioner) orders…””

“Based on observation, interview, and record review, the hospice (a specialized, holistic, and compassionate care program for people with a terminal illness) agency failed to ensure that it followed accepted standards of practice to prevent the transmission of infections and communicable diseases when Hospice Aide (HA) 2 did not wash or sanitize her hands in between glove changes while providing direct patient care for Patient 2.This deficient practice could lead to a potential risk of infection for Patient 2. Findings:During an observation on 4/21/26 at 10:29 AM, HA 2 was observed giving a bed bath (a hygiene procedure where a person confined to bed is washed with soap and water [or no-rinse wipes] by a caregiver, often termed a “sponge bath” or “blanket bath”) to Patient 2. During the course of the bed bath, HA 2 changed her gloves multiple times and did not sanitize or wash her hands in between glove changes.During an interview on 4/21/26 at 11:17 AM with HA 2, HA 2 stated that she should have sanitized her hands in between glove changes while giving Patient 2 a bed bath. CNA 2 confirmed that she changed her gloves multiple times but forgot to sanitize her hands when removing them and putting new gloves on. CNA 2 also stated that Patient 2 would be at risk for contamination and other infection controls issues if she did not sanitize or wash her hands more often. During an interview on 4/21/26 at 11:40 AM with RN 3, RN 3 stated that her expectation was for the HA’s to either sanitize or wash their hands in between glove changes. RN 3 also stated that hospice patients were more prone to infections and that staff needed to sanitize or wash their hands to prevent the patients from getting infections.During an interview on 4/21/26 at 1:08 PM with the Clinical Coordinator (CC), the CC stated that her expectation was for the HA’s to sanitize their hands in between glove changes while they were providing patient care. The CC also stated that the patients would be at risk for cross-contamination and other infections or illnesses. The CC further stated that the staff should have been especially careful with hand hygiene while doing perineal care (also known as peri care which is crucial for daily cleansing of the genital and anal areas to maintain hygiene, comfort, and prevent infections, particularly for immobile or incontinent patients).During an interview on 4/22/26 at 11:30 AM with the Director of Patient Care Services (DPCS- A senior leadership individual responsible for overseeing all clinical operations, staff supervision, and compliance with regulations), the DPCS stated that her expectation was for the staff to sanitize or wash their hands in between glove changes while providing direct patient care. The DPCS also stated that the patients would be exposed to bacteria and other infection control issues if staff were not cleaning their hands accordingly.During a review of the facility’s policy and procedure (P&P) titled, “HAND HYGIENE,” revised 11/24, the P&P indicated, “…PURPOSE …To prevent cross-contamination and hospice-acquired infections …Personnel providing care in the home setting will regularly wash their hands …Hand decontamination using an alcohol-based hand rub should be performed: …When moving from a contaminated body site to a clean body site during patient care …After removing gloves …”During a review of the facility’s P&P titled, “STANDARD PRECAUTIONS,” revised 11/24, the P&P indicated, “…PURPOSE …To reduce the risk of exposure to and transmission of infections when caring for patients …Hand hygiene will be performed to prevent cross-contamination between the patient and personnel …When hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands …””

“Based on interview and record review, Registered Nurse (RN) 1, RN 2, and RN 3, failed to make on-site supervisory visits for Hospice Aide (HA) 1 assigned to provide care for 1 of 15 sampled patients (Patient 1).This failure had the potential to result in inadequate or inappropriate healthcare practices by HA 1 resulting in less than desirable care being provided for Patient 1. Findings:During a concurrent interview and record review on 4/22/26 at 2:25 PM with the Director of Patient Care Services (DPCS- A senior leadership individual responsible for overseeing all clinical operations, staff supervision, and compliance with regulations), the Electronic Health Record (EHR) for Patient 1 was reviewed. The DPCS confirmed that HA 1 had home visits for Patient 1 on 8/11/25, 8/14/25, 8/18/25, 8/21/25, 8/25/25, 8/28/28, 9/1/25, 9/4/25, and 9/8/25. The DPCS also confirmed that RN 1 conducted home visits for Patient 1 on 8/11/25 and 9/8/25, RN 2 conducted a home visit on 8/23/25, and RN 3 conducted home visits on 8/21/25, 8/25/25, and 9/5/25. The DPCS further confirmed that RN 1, RN 2, and RN 3 did not conduct a supervisory visit for HA 1 from 8/11/25 to 9/8/25 while she was providing care for Patient 1.During an interview on 4/22/26 at 2:35 PM with the DPCS, the DPCS stated that it was her expectation for the RN’s at the agency to conduct on-site supervisory visits for HA’s every 14 days. The DPCS also stated that the RN’s needed to do supervisory visits for the HA’s to ensure that they were following the plan of care and providing the assigned care duties for the patients. The DPCS further stated that the RN’s also needed to make sure the HA’s were following proper infection control procedures while providing care. The DPCS explained that the computer software program that the RN’s were using previously was discontinued and it took a while for the RN’s to learn the new computer software program.During a review of the facility’s policy and procedure (P&P) titled, “RESPONSIBILITIES/SUPERVISION OF CLINICAL SERVICES,” revised 11/24, the P&P indicated, “…To ensure that a qualified individual is responsible for overseeing all clinical care and services …Hospice aide supervisory visits will be conducted on-site at least every 14 days by a hospice registered nurse …””

“Based on interview and record review, the hospice (a specialized, holistic, and compassionate care program for people with a terminal illness) agency failed to ensure volunteer services equaled 5% of the total patient care hours of all paid hospice employees and contracted staff in the year 2025.This failure had the potential for decreased quality of care and quality of life for a patient census of 77 in 2025. Findings:During a concurrent interview and record review on 4/22/26 at 11:35 AM with the Director of Patient Care Services (DPCS- A senior leadership individual responsible for overseeing all clinical operations, staff supervision, and compliance with regulations), an undated facility provided document titled, “[facility’s name] Hospice – [facility’s location] Volunteer Program 2025,” was reviewed. Upon review, the DPCS confirmed that the total volunteer utilization for 2025 was 3.84% and did not reach the minimum 5% threshold. The DPCS stated that it was a service failure for the patients by not fully utilizing the volunteers. The DPCS also stated that the patients would receive less interaction and they could miss out on some patient care services.During an interview on 4/22/26 at 11:40 AM with the Clinical Coordinator (CC), the CC stated that by not having enough volunteers to help provide care, the nursing staff would have to compensate. The CC also stated that the plan of care would be affected and that the patients and family members would not be able to receive certain care services. The CC further stated that her expectation was for the hospice to use at least 5% in volunteer services and that they currently did not reach that mark for the year 2025.During a review of the facility’s policy and procedure (P&P) titled, “DOCUMENTATION OF VOLUNTEER UTILIZATION,” revised 11/24, the P&P indicated, “…The hours of volunteer services will exceed 5% of the total day-to-day administrative or direct patient care hours of paid and contracted hospice personnel …Volunteer service hours to show that volunteer hours equal at least 5% of the total day-to-day administrative or direct patient care hours of all paid hospice and contract staff …””

“Based on interview and record review, the facility failed to ensure physicians orders were in place for two of seven sampled patients (Patient 5 and Patient 6), when Patient 5 and Patient 6 received visits from licensed nurses, home health aides, and/or Medical Social Worker (MSW) without current physician orders for the frequency of visits.This failure had the potential for Patient 5 and Patient 6’s health care needs being unmet resulting in a decline in health and wellbeing. Findings:a. Review of Patient 5’s clinical document titled, “Patient Profile [contains clinical and demographic data],” undated, indicated Patient 5 was admitted with diagnoses which included heart failure and dementia (a decline in mental ability severe enough to interfere with daily life, caused by physical changes in the brain).Review of Patient 5’s visit schedule indicated Patient 5 received visits from a licensed nurse on 3/20/26, 3/23/26, 3/25/26, 3/27/26, 3/30/26, 4/1/26, 4/3/26, 4/6/26, 4/8/26, 4/10/26, 4/13/26, 4/16/26, and 4/20/26.Review of Patient 5’s most recent clinical document titled, “Hospice Physician Order,” dated 1/6/26 (for benefit period 12/20/25-3/19/26), indicated there were no current physician orders in place for licensed nursing visits which occurred on 3/20/26, 3/23/26, 3/25/26, 3/27/26, 3/30/26, 4/1/26, 4/3/26, 4/6/26, 4/8/26, 4/10/26, 4/13/26, 4/16/26, and 4/20/26.During a concurrent interview and review record on 4/21/26 at 4:22 PM with the Administrator (ADM), of Patient 5’s physician orders, the ADM confirmed there were no current physician orders for Patient 5’s licensed nursing visits that occurred on 3/20/26, 3/23/26, 3/25/26, 3/27/26, 3/30/26, 4/1/26, 4/3/26, 4/6/26, 4/8/26, 4/10/26, 4/13/26, 4/16/26, and 4/20/26.b. Review of Patient 6’s clinical document titled, “Patient Profile,” undated, indicated Patient 6 was admitted with diagnoses which included senile degeneration of the brain (a general term for the progressive, age-related decline in mental function, characterized by brain cell damage, significant memory loss, and reduced cognitive abilities).Review of Patient 6’s visit schedule indicated Patient 6 received visits from a licensed nurse on 2/4/26, 2/6/26, 2/11/26, 2/13/26, 2/18/26, 2/20/26, 2/25/26, 2/27/26, 3/4/26, 3/6/26, 3/11/26, 3/13/26, 3/18/26, 3/20/26, 3/25/26, 3/27/26, 3/30/26, 4/1/26, 4/3/26, 4/8/26, and 4/10/26, from a home health aide on 2/3/26, 2/6/26, 2/10/26, 2/12/26, 2/17/26, 2/20/26, 2/24/26, 2/27/26, 3/3/26, 3/6/26, 3/10/26, 3/13/26, 3/17/26, 3/20/26, 3/24/26, 3/27/26, 3/31/26, 4/3/26, 4/7/26, and 4/10/26. Further review of Patient 6’s visit schedule indicated a MSW visited Patient 6 on 1/30/26 and 3/19/26.Review of Patient 6’s most recent clinical document titled, “Hospice Physician Order,” dated 11/6/25 (for benefit period 10/15/25-1/12/26), indicated there were no current physician orders in place for licensed nursing visits, home health aide visits and MSW visits which occurred on above listed dates.During a concurrent interview and review record on 4/21/26 at 4:22 PM with the Administrator (ADM), of Patient 6’s physician orders, the ADM confirmed there were no current physician orders for Patient 6’s licensed nursing visits, home health aide visits and MSW visits that occurred on above listed dates. The ADM stated patient care could be jeopardized when there were no physician orders for visits provided to the patients.During an interview on 4/22/26 at 1:09 PM, with the Director of Patient Care Services (DPCS), the DPCS stated the expectation was to update physician orders with any changes and to update with every benefit period/recertification period. The DPCS explained the risk to the patient could be a delay in care, medication issues and not following physician orders if care providers were not aware of how often they should see the patient.”

“Based on interview and record review the facility failed to ensure the most recent hospice plan of care was provided to the skilled nursing facility (SNF, provides 24/7 licensed medical care and long-term care for individuals needing more complex services than home care) for one of four sampled hospice patients (Patient 7) residing in a SNF when Patient 7’s hospice plan of care had not been updated in the hospice binder at the SNF since January 20, 2026.This failure had the potential to negatively impact Patient 7’s health and wellbeing related to facility staff not having the most recent plan of care for Patient 7 available. Findings:A review of Patient 7’s clinical document titled, “Patient Profile,” undated, indicated Patient 7 was admitted with diagnoses which included senile degeneration of the brain (a progressive, age-related decline in cognitive function caused by structural brain changes).During a concurrent interview and record review on 4/21/26 at 1 PM, with licensed nurse (LN) 2, LN 2 confirmed the most recent Plan of Care for Patient 7 in Patient 7’s hospice binder at the SNF was dated 1/20/26. LN 2 explained the Plan of Care was updated every 15 days and should be updated in Patient 7’s hospice binder on the next visit following the update. LN 2 further confirmed five previous Plan of Care updates had not been put in Patient 7’s hospice binder at the SNF. LN 2 explained the importance of the SNF having the updated Plan of Care was for coordination of care of Patient 7. LN 2 further explained the risk to Patient 7 was new orders would not be initiated in a timely manner.During an interview on 4/22/26 at 1:07 PM, with the Director of Patient Care Services (DPCS), the DPCS stated the expectation was for the hospice binders at the skilled nursing facility should be updated every time there was a new Plan of Care, which occurs every 15 days. The DPCS explained the risks to the patient were not following the Plan of Care, patient safety, and medication hazards. The DPCS further explained if the patient had issues with body mechanics (the way we move our bodies during daily activities, focusing on using proper posture, balance, and alignment to lift, carry, and move objects efficiently without injury) and the most recent, updated Plan of Care was not available the home health aide and facility staff would not be aware of the changes and how to care for the patient.During an interview on 4/22/26 at 4:24 PM, with the Administrator (ADM Sac), the ADM Sac stated the most recent Plan of Care should be in the hospice binder at the facility. The ADM Sac explained the facility would not know what the updated Plan of Care was and would not be aware of any updates. The ADM Sac explained the risk to the patient was patient care could be jeopardized due the facility being unaware of any new treatment orders and medications orders. The ADM Sac further explained if the patient had a wound the wound could get worse. The ADM Sac explained if there was a new medication order, the facility may not be aware of the new medication. The ADM Sac stated overall patient care could be compromised.”

“Based on observation and interview, the facility failed to ensure the safety of one of 4 sampled hospice patients (Patient 7) residing in a skilled nursing facility (SNF-provides 24/7 licensed medical care and long-term care for individuals needing more complex services than home care), when licensed nurse (LN) 2 failed to ensure Patient 7’s wheelchair was locked prior to assisting Patient 7 into a standing position from the wheelchair.This failure had the potential to result in a fall causing injury to Patient 7, negatively impacting Patient 7’s health and wellbeing. Findings:A review of Patient 7’s hospice clinical document titled, “Patient Profile,” undated, indicated Patient 7 was admitted with diagnoses which included senile degeneration of the brain (a progressive, age-related decline in cognitive function caused by structural brain changes).During an observation on 4/21/26 at 12:47 PM, with LN 2 in Patient 7’s room, LN 2 was observed assisting Patient 7 into a standing position from Patient 7’s wheelchair (w/c). LN 2 did not lock the brakes on Patient 7’s w/c prior to assisting Patient 7 into a standing position.During an interview on 4/21/26 at 1 PM, with LN 2, LN 2 confirmed she had not locked Patient 7’s w/c prior to assisting Patient 7 into a standing position but should have. LN 2 stated the importance of locking the w/c prior to assisting Patient 7 into a standing position was to prevent falls and added it was just during this visit that she noticed Patient 7’s left w/c brake was not functioning properly. During an interview on 4/22/26 at 1:02 PM, with the Director of Patient Care Services (DPCS), the DPCS stated the expectation for assisting a patient into a standing position from a w/c was to ensure the brakes were locked for patient safety. The DPCS stated the risk to the patient was a risk of the w/c sliding out from underneath the patient.”