Failure to Provide Adequate Supervision and Safe Transport Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including dementia, diabetes, rheumatoid arthritis, and a recent left proximal fibular fracture, was not provided with adequate supervision and assistance devices during transport to a medical appointment. The resident, who required extensive assistance for mobility and transfers and was non-ambulatory, was being transported in a facility van operated by a staff member who had only received 30 minutes of training from another driver. During the trip, the driver braked abruptly for a red light, causing the resident to slide out of her wheelchair and fall onto the van floor, resulting in a nondisplaced fracture of the left proximal fibular metaphysis, as well as abrasions and skin tears to both knees and other minor injuries. Interviews and record reviews revealed inconsistencies regarding the use of safety restraints. The driver stated that all wheelchair straps and seat belts were secured, while the resident's responsible party believed the resident had not been properly strapped in, as she slid forward and hit her head on the back of the driver's seat. The resident herself could not recall whether a seat belt was in use at the time of the incident. Maintenance staff confirmed that the van's equipment, including seat belts and wheelchair tie-downs, was in good working order following the incident. The resident was assessed at the hospital, where imaging confirmed the left knee fracture and other injuries. The facility's documentation indicated that the resident's care plan included interventions for pain management and trauma risk, and that she required two-person assistance for transfers. The incident report and subsequent interviews highlighted that the driver was the only staff member present during transport, and that the responsible party assisted in repositioning the resident after the fall. The event demonstrated a failure to ensure adequate supervision and proper use of assistance devices during resident transport, directly resulting in the resident's injuries.