Failure to Provide Safe Transport and Immediate Medical Assessment After Resident Fall
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical diagnoses, including dementia, major depressive disorder, lung cancer, panic disorder, and difficulty walking, was transported alone by the facility Administrator to a medical appointment. The resident, who was non-ambulatory and dependent on a wheelchair, was not accompanied by a nurse or CNA as required by facility policy. During the return trip, the resident fell from the wheelchair onto the floor of the facility van and was not properly secured or supervised. After the fall, the Administrator did not seek emergency medical assistance and instead transported the resident back to the facility while she remained lying on the van floor for approximately 42 miles. The resident was unresponsive verbally after the fall and was lodged between the wheelchair and a van seat, with her legs extended and the seatbelt loose. The Administrator did not notify emergency services or licensed staff during the transport, and the resident was not assessed by licensed personnel for approximately 30 minutes until arrival at the facility. Upon arrival, the resident was assessed by the DON and ADON, who found her on the van floor with no apparent injuries and a pain rating of zero. Emergency services were contacted only after the resident returned to the facility. The incident was determined to be Immediate Jeopardy and Substandard Quality of Care due to the failure to provide adequate supervision, ensure safe transport, and obtain immediate medical assistance following the accident.