Failure to Assess Resident for Injury Prior to Movement After Fall During Transport
Penalty
Summary
A deficiency occurred when a resident, who had a history of stroke with right-sided hemiparesis, end-stage renal disease requiring dialysis, anxiety, and depression, was being transported to a medical appointment. During the trip, the transportation driver made an abrupt stop to avoid a collision, causing the resident to slide out of her wheelchair and wedge her left foot under the driver's seat. The driver, who was a Nursing Assistant and Medication Assistant but had not received specific training for such emergencies, pulled the resident's foot out, repositioned her in the wheelchair, and continued driving to the hospital without having the resident assessed for injury by a qualified professional prior to moving her. Upon arrival at the hospital, the resident had again slid out of the wheelchair, with her back against the legs of the wheelchair and the rest of her body on the floor of the van. The resident was observed to have a visibly swollen ankle and was in significant pain. Hospital staff assisted in moving the resident and directed that she be taken to the Emergency Department, where she was diagnosed with a nondisplaced trimalleolar fracture of the left ankle. The resident required pain management and immobilization of the ankle. Interviews with the transportation driver, the resident, the facility administrator, and the physician confirmed that the resident was not assessed by a licensed medical professional prior to being moved after the fall. The physician specifically stated that residents should always be assessed after a fall by a licensed professional before being moved, as moving without assessment could result in further injury. The transportation driver admitted to not contacting the facility immediately and to lacking training on emergency procedures during transport.