Resident Injury During Transport Due to Inadequate Supervision and Accident Hazard
Penalty
Summary
A deficiency occurred when a resident with impaired mobility, spinal stenosis, dementia, and moderate cognitive impairment slid from their wheelchair onto the floor of a facility vehicle during transport. The resident, who required significant assistance for transfers and weighed 282 pounds, was being transported by a CNA to a physician appointment. During the appointment, the resident repeatedly slid down in their wheelchair, removing their feet from the footrests and not sitting upright, which the CNA attributed to discomfort from a medical boot. The CNA repositioned the resident multiple times but proceeded with the return trip alone, believing it would not be a problem since previous transports had been successful. While driving back, the resident expressed feeling like they were slipping out of the wheelchair. The CNA pulled into a parking lot to assist, but the resident slid onto the van floor before help could be provided. The resident was found wedged between the wheelchair and the van's front seats. The CNA was unable to lift the resident back into the wheelchair due to the resident's size and called for EMS, who assisted in returning the resident to the wheelchair. The resident declined transport to the hospital at that time and was brought back to the facility, where it took four staff members to get the resident inside. Subsequent assessments revealed a 12 cm scratch on the resident's buttock, bruising on the left abdomen, and complaints of significant abdominal pain. An x-ray was ordered, and the resident was later sent to the hospital, where a large left abdominal rectal sheath hematoma was diagnosed. The incident was not immediately reported to nursing staff by the CNA, and the DON later stated that staff should have been informed of the fall and that additional assistance should have been sought when the resident had difficulty remaining in the wheelchair.