Failure to Ensure Safe Transport and Supervision Resulting in Resident Fall and Altercation
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, limited mobility, and contractures was not safely secured during transport in a specialized wheelchair by a contracted transportation company. The driver failed to secure the resident in accordance with the manufacturer's instructions for the van's 4-point anchor tie-down system and seatbelt application. As the van entered the facility driveway and hit a bump, the resident slid out of the wheelchair and onto the van floor, with the seatbelt found around the wheelchair rather than properly restraining the resident. Facility staff assisted the resident back into the wheelchair, and the resident was subsequently assessed and transported to the emergency department, where no injuries were found. The resident involved had a history of end-stage kidney disease, encephalopathy, cerebral infarction, muscle weakness, and was on anticoagulant therapy. The resident required a mechanical lift for all transfers and was totally dependent on staff for activities of daily living. The specialized wheelchair used was not designed for vehicle transport, and both the transport company and facility staff noted challenges in securing the resident safely due to the wheelchair's construction. The transport company owner reported previous concerns about the safety of transporting this resident in the specialized chair, but there was no documentation of these concerns prior to the incident. Additionally, the facility failed to provide effective supervision to prevent a resident-to-resident altercation. In a shared room, one resident with severe cognitive impairment and behavioral issues struck another resident in the face during a dispute over a television remote. The altercation resulted in a small bruise on the hand of the resident who was struck, but no visible injury to the face or lip. Staff responded by separating the residents and assessing them for injuries. The incident was reported to the appropriate authorities, and the residents were interviewed about the event.