Failure to Provide Adequate Supervision and Accident Prevention During Resident Transport
Penalty
Summary
The facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents during transportation, resulting in two separate incidents involving two residents. In the first incident, a female resident with diabetes, heart failure, and vision loss, who was cognitively intact and independent in her activities of daily living, was being transported in the facility van. The driver did not properly secure the resident's wheelchair, causing it to tip backward when the van accelerated. The resident reported hitting her head on the ramp and experiencing a headache, though she had a headache prior to the incident. The driver admitted to not fully securing the wheelchair and did not immediately report the incident to the Administrator, instead informing the nurse upon return to the facility. In the second incident, a male resident with kidney failure, diabetes, heart failure, and Parkinson's disease, who required minimal assistance with activities of daily living and used a wheelchair, was being unloaded from the facility van. The driver failed to secure the safety strap on the lift and lost her balance, falling onto the resident. This caused the resident's wheelchair to roll backward off the lift and tip over, resulting in the resident hitting his head on the ground and sustaining a scalp abrasion. The driver had previously received in-service training on transport procedures but did not follow the required protocols during this incident. Both incidents were attributed to staff failing to follow established procedures for securing residents and their wheelchairs during transport. In both cases, the drivers had received prior training on transport safety but did not adhere to the protocols, leading to the residents being placed at risk for injury. The facility did not have a specific policy for transporting residents and relied on the company's driver training manual.