Annette closed the big notebook that was her mother Penelope’s chart in the skilled nursing facility. Now it was time to observe her directly. Unseen by her mother, Annette watched Penelope try hoist herself up out of a wheelchair. A nurse noticed the motion, then quickly walked over.

“Do you want to stand up and walk to your room?” she asked Penelope in a clear, pleasant voice.  “I’ll help you.”

Since Annette’s last visit, Penelope had deteriorated significantly.  Even with the nurse’s help, Penelope was hunched over and listing to one side, walking glacially slowly.

In the aftermath of a fall two months earlier, Penelope no longer walked unaided.  When she was taken to the hairdresser, the fitness center, the coffee shop or anywhere else outside of her immediate 30-bed unit in the sprawling facility, aides typically grabbed any available transport chair (a simple, stripped down version of a wheelchair) to put her in.  When they returned to the unit, they often left Penelope in the chair in the common area.

The next day, Annette walked along beside Penelope as an aide pushed her in a transport chair to a sing-along in an activities room a few hallways away. Glancing down, Annette was surprised to see that her mother looked very unhappy – almost terrified – as the aide very slowly pushed the chair.  Penelope grasped the armrests of the chair in a death grip, knuckles white.  Why? 

Suddenly, Annette understood.  The chair that the aide had gotten, the only one available right then, was an oversized one. Penelope was very short and thin. You could fit three of her in that chair, with room to spare.  Each time the chair jostled her a little as it went over doorsills and from carpet to tile, she clearly felt unsteady and it scared her.

“No one,” Annette thought, “should be terrorized by a wheelchair.”

Later, she spoke to one of the nurses.

“My mother seems upset when she is pushed in a transport chair.”

“Yes,” the nurse said, “she doesn’t find it very comfortable.  Those chairs just have a fabric seat.  Whenever I see that she’s been brought to the common area and just left in a transport chair, I insist that she be helped out of it to sit in a regular chair.  I often see her trying to get out of the transport chair, even if she isn’t trying to go anywhere.”

“Those chairs are so much bigger than she is,” Annette continued.  “She rattles around in them and it seems to upset her.  Can she be fitted for her own chair, one that’s her size, and have a cushion gotten for it, to help her be more comfortable in it?”

“Of course,” the nurse said.  “I agree with you.  I think she would be much happier.  We’ll have the physical therapy department come measure her.  It may even be that she needs a pediatric chair, to get the right fit.”

Everyone agreed that Penelope should still be encouraged to walk as much as possible; having her own chair was simply a way to make her more comfortable when she was going to be in a transport chair anyway. After Annette had returned home, and knew that the chair had been in use for a few days, she called in to ask how Penelope liked it.

“Oh, it’s great!” the nurse said.  “She seems so comfortable now.  And I haven’t seen her struggling to get out of it just to go sit in another chair that’s more cushioned.  She seems very happy with it.”

Annette saw her mother only occasionally.  The facility was full of nurses, companions and aides who saw her every day.  They took very good care of Penelope, completing dozens of care activities every day, helping her dress, eat, bathe, walk, and so forth.  They all knew that Annette would pay for anything Penelope needed.

But there was no action step that said to figure out if the resident was scared of a wheelchair. Annette realized that it took someone watching her mother’s face and noticing the expression on it, and observing her body language, to recognize a problem that needed attention.  And that’s hard to translate into a checklist.