Failure to Provide Immediate Medical Assistance and Safe Transport After Resident Fall
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect when it did not obtain immediate medical assistance after the resident sustained a fall from a wheelchair in the facility van. The resident, who had severe cognitive impairment and was non-ambulatory, was being transported alone by the Administrator without the assistance of a nurse or CNA. During the transport, the resident slipped from the wheelchair and ended up lying on the floor of the van. The Administrator did not seek emergency assistance and instead transported the resident back to the facility while she remained on the floor for approximately thirty minutes. Upon arrival at the facility, the resident was found lodged between the wheelchair and a van seat, unrestrained, with her legs extended. The Administrator had not contacted emergency services or notified nursing leadership during the return transport. The resident was not assessed by licensed personnel until arrival at the facility, at which point the DON, ADON, QA nurse, and LPN assessed her. Emergency services were only contacted after the resident arrived back at the facility. The resident had a history of major depressive disorder, dementia, lung cancer, panic disorder, and difficulty walking, and was dependent on a wheelchair for mobility. The facility's policies required that residents be transported with appropriate supervision and safety measures, including being secured with seatbelts or wheelchair tie-downs and accompanied by qualified staff. These protocols were not followed, resulting in the resident being transported unsafely and without timely medical assessment after a fall.