Failure to Provide Safe Supervision and Equipment During Resident Transport Resulting in Injury
Penalty
Summary
A deficiency occurred when the facility failed to ensure adequate supervision and safe assistance devices to prevent accidents for a resident with significant medical needs. The resident, a male with a history of morbid obesity, legal blindness, chronic obstructive pulmonary disease, osteoarthritis, and previous right femur and tibia fractures, required extensive assistance for mobility and transfers. Despite these needs, the resident was transported in a bariatric shower chair after a shower, during which the chair tipped and the resident fell, resulting in a right femur fracture. The incident report and interviews revealed that the resident was still wet from the shower, the wheels of the chair became crooked, and the chair was pushed forward at an angle, causing the resident to fall and sustain injury. Interviews with staff indicated that the shower chair was believed to be appropriate for the resident's weight, and maintenance records showed the chair had been inspected and was within its weight limit. However, the incident occurred when the resident adjusted himself in the chair and indicated he was ready to be transported, but was not fully settled. The CNA transporting the resident did not stop to ensure the resident was properly positioned before moving, and when the chair's wheel got stuck while rounding a corner, the CNA pushed the chair forward, leading to the tip and fall. The resident reported immediate pain and gross deformity, and was subsequently hospitalized for a right distal shaft femur fracture. The facility's investigation initially ruled out abuse and neglect, citing that the fall was witnessed, the equipment was within weight limits, and the staff member had not acted improperly according to their policies. However, the investigation was later reopened, and it was found that the facility failed to provide adequate supervision and did not ensure the safe use of assistance devices during resident transport, directly resulting in the resident's injury. The event led to increased anxiety for the resident around shower times and a reduced quality of life.