Neglect Following Unreported Fall During Resident Transport
Penalty
Summary
A deficiency occurred when a contracted transport driver failed to protect a resident from neglect during transportation from a medical appointment. The resident's wheelchair flipped backwards in the transport van, causing the resident to fall and sustain a head and back injury. The driver, who was not qualified to assess injuries, asked the resident if she was okay, set the wheelchair upright, secured it, and continued the trip without seeking medical evaluation or notifying facility staff of the incident. Upon arrival at the facility, the driver only informed staff that the resident was not feeling well and wanted to go to bed, deliberately withholding information about the fall. The resident later reported severe pain in her neck, shoulders, and back, rating it as 10 out of 10, and staff observed her in significant distress. Despite administration of opioid pain medication, the resident's pain persisted, and she was subsequently transferred to the hospital, where she was diagnosed with a fracture at the superior endplate of the L1 vertebra. The contracted transport driver's actions, including moving the resident without a clinical assessment and failing to report the fall to facility staff, resulted in delayed care and prolonged suffering for the resident. The facility's initial report identified the driver as the accused individual in an allegation of neglect, and the incident was determined to constitute neglect due to the disregard for the resident's need for timely clinical assessment and appropriate care following the fall.
Removal Plan
- Ceased use of the vendor for the company that provided transportation for Resident #1.
- Completed an audit of all facility falls to verify that all residents were assessed by a licensed nurse for injury following a fall and that non-medical staff notified qualified staff to perform a clinical assessment prior to the resident being moved.
- Completed an investigation for any concerns identified during the audit and took appropriate follow-up action based upon the results.
- Provided training for all contract transport drivers from the new Transportation Vendor on notifying 911 to assess the resident for injury prior to moving the resident and the requirement to notify the facility of falls by calling the facility at the time of the fall after calling 911.
- Provided training for contract transport drivers on identifying and reporting neglect, including examples of what constitutes neglect, completed by Contract Transportation Vendor Supervisors.
- Required that all contract transport drivers for the Transportation Vendor complete this training prior to being assigned transportation trips for facility residents, with documentation provided to the Administrator.
- Required that newly hired contract transport drivers for this vendor receive this training prior to being assigned transportation trips for facility residents.
- Re-educated 100% of facility staff regarding the facility policy for Abuse Identification, including indicators of neglect and reporting neglect, with examples.
- Department Supervisors provided this education for their respective staff, and all staff who did not complete this training received it prior to working their next shift.
- Clinical Competency Coordinator responsible for tracking to ensure 100% of staff receive the training, including during general orientation for all newly hired staff.
- Re-educated 100% of facility staff regarding the facility policy not to move the resident after a fall until examined by a licensed nurse for possible injuries.
- Provided training to 100% of the facility's transport drivers related to ensuring the resident is assessed by a qualified professional in the event a fall occurs during transportation and prior to moving the resident, including calling 911 and notifying the facility.
- Required that newly hired facility transportation drivers receive this training prior to being assigned transportation trips for facility residents.