Failure to Provide Required Supervision During Resident Transport Results in Fall and Injury
Penalty
Summary
A deficiency occurred when a resident who required supervision and assistance with ambulation was sent to an outside medical appointment without an escort, contrary to facility policy. The resident had a history of muscle weakness, abnormal gait, and impaired balance, as documented in clinical records and therapy assessments. The care plan and therapy evaluations consistently indicated the need for standby assistance during ambulation, especially on uneven surfaces and in community settings. On the day of the incident, the resident was transported by ambulance to a medical appointment. Upon arrival, the resident was dropped off in front of the building and proceeded to walk into the building unassisted, using a rolling walker. There was no staff member or family escort present to provide the required supervision. The resident subsequently tripped over a thick mat in the lobby, resulting in a fall and a fractured nasal bone. Facility policies reviewed in the report specified that residents requiring supervision should be accompanied by staff if family is unavailable, and that individualized safety interventions must be communicated and implemented. Despite these policies and the resident's documented need for supervision, the facility failed to provide an escort, leading to actual harm. Staff interviews confirmed the resident's ongoing need for standby assistance and the lack of supervision at the time of the fall.