Failure to Prevent Accident During Resident Transport Resulting in Knee Fracture
Penalty
Summary
The facility failed to provide adequate supervision and assistance to prevent accidents, resulting in actual harm to a resident who sustained a patella (knee) fracture. The resident, who had diagnoses including epilepsy, a history of falls, and muscle weakness, was cognitively intact according to the most recent assessment. During transport back to the facility from an appointment, the resident's left leg fell off the wheelchair footrest and became caught under the wheelchair. Despite the resident expressing pain and asking the driver to stop, the driver continued pushing the wheelchair, unaware of the injury until alerted by the resident's reaction and bystanders. Documentation and staff interviews confirmed that the van driver did not notice the resident's leg had fallen off the footrest and did not immediately report the incident. The resident continued to experience pain, and subsequent imaging revealed a mid-patella fracture. The facility's own policy required thorough investigation and timely response to incidents, but the lack of adequate supervision and failure to promptly recognize and address the resident's distress directly led to the injury.