Failure to Ensure Clinical Assessment After Resident Fall During Transport
Penalty
Summary
A contracted transport driver failed to have a resident assessed for injury by a qualified professional prior to moving the resident after a fall in a transportation van. The driver also did not notify facility nursing staff of the fall, which delayed the clinical assessment and treatment of the resident. Upon return to the facility, the resident reported severe pain in the neck, shoulders, and back, and it was later determined that the resident had suffered a fracture at the superior endplate of the L1 vertebra. The resident involved had a history of left above-the-knee amputation, right below-the-knee amputation, and was dependent on dialysis. The resident was severely cognitively impaired, dependent on staff for transfers, and used a wheelchair for mobility. The incident occurred when the resident's wheelchair flipped backwards in the van due to the driver failing to secure it. The driver lifted the resident and the wheelchair back upright without a clinical assessment and returned the resident to the facility, only reporting that the resident was in pain and wanted to go to bed, without disclosing the fall. Facility staff became aware of the incident only after the resident reported the fall and her pain. The nurse on duty assessed the resident, administered pain medication, and contacted the physician, who ordered the resident to be sent to the emergency department. The contracted transport driver did not follow required procedures for reporting and responding to the fall, and the lack of immediate clinical assessment posed a high likelihood of further injury and delayed necessary treatment.
Removal Plan
- The Director of Nursing (DON) will review all facility falls to verify that all residents were assessed by a licensed nurse for injury following a fall and non-medical staff notified staff who were qualified to perform clinical assessments prior to the resident being moved. The facility will complete an investigation for any concerns that are identified and take appropriate follow-up action based upon the results of the investigation. The Administrator will assume responsibility to ensure the investigation and follow-up are completed.
- The Contracted Transportation Company Owner will provide training for all contract transport drivers who transport residents from the facility. Training will be provided by the Contract Transportation Vendor Supervisors and will include 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. All contracted transport drivers this Transportation Vendor sends to the facility will have this training completed prior to being assigned transportation trips for the facility residents. Training documentation will be provided to the Administrator by the Contracted Transportation Company Owner or Designee to be maintained at the facility. Newly hired contract transport drivers for this vendor will be provided this training by the Contracted Transportation Company Owner or Designee prior to being assigned transportation trips for the facility residents.
- Facility staff will receive re-education provided by the Administrator regarding the facility policy not to move the resident after a fall until he/she has been examined by a licensed nurse for possible injuries. Department Supervisors will provide this education for their respective staff. All staff who did not complete this training will have the training provided prior to working their next shift, provided by their respective Department Supervisor. The Clinical Competency Coordinator will be responsible for tracking to ensure that 100% of staff receive the training. This training will be provided during general orientation for all newly hired staff.
- Facility's transport drivers will receive training related to ensuring the resident is assessed by a qualified professional in the event the fall occurs during transportation and prior to moving the resident. Per the policy, they should move to the side of the road and call 911 for resident assessment by a qualified professional. Per policy, the facility transport driver will notify the facility of any fall that occurs during transport. The facility's Transport Driver training was provided by the facility Maintenance Director.
- Newly hired facility transportation drivers will be provided training related to ensuring the resident is assessed by a qualified professional in the event the fall occurs during transportation and prior to moving the resident. Per the policy, they should move to the side of the road and call 911 for resident assessment by a qualified professional. Per policy, the facility transport driver will notify the facility of any fall that occurs during transport provided by the Maintenance Director.