Failure to Supervise Resident During Geri-Chair Transport
Penalty
Summary
The facility failed to assess the risks associated with transporting residents backwards in Geri-Chairs and did not provide adequate supervision during these transports. Specifically, a resident with cerebellar ataxia, cognitive communication deficit, and muscle spasms was observed being pulled backwards in a Geri-Chair by a CNA who was not attentive to the resident during the transport. The resident was visibly distressed, crying out, kicking, and attempting to move in the chair while being transported. The facility's records indicated that this resident had experienced three previous falls from her wheelchair, each related to lack of supervision when she was moving about and kicking, with one incident resulting in a head injury that required hospital care. The DON confirmed that staff were expected to be attentive during such transports but were not in this instance.