Failure to Prevent Accidents and Inadequate Supervision Resulting in Resident Injury and Elopement
Penalty
Summary
The facility failed to ensure the use of wheelchair foot pedals during transportation for two residents, resulting in one resident sustaining significant injury. One resident, who had recently undergone right knee replacement surgery and was admitted for rehabilitation, was transported by a physical therapy assistant in a wheelchair without foot pedals. The resident, unable to hold her leg up due to weakness and fatigue, dropped her right leg as the wheelchair crossed a threshold, causing her ankle to twist and resulting in acute nondisplaced fractures of the medial and lateral malleoli. The resident's medical records confirmed the absence of prior ankle pain or injury, and both the staff involved and the director of nursing acknowledged that the lack of foot pedals contributed to the injury. Another resident, who had a recent clavicle fracture and was receiving therapy, was also observed being transported in a wheelchair without foot pedals, requiring her to hold her feet up during transport. Staff confirmed that foot pedals were not in use and should have been applied. Additionally, the facility failed to provide adequate supervision for a cognitively impaired resident at risk for elopement. The resident, who had a documented history of dementia and was assessed as low risk for elopement, was able to exit the memory care unit through an alarmed door and was found in a nearby church parking lot by a visitor. The incident was not reported to the administrator or medical director, and the facility's missing resident policy was not followed. There was no immediate reassessment of the resident's elopement risk or update to the care plan following the incident, and required notifications and documentation were not completed as outlined in facility policy. These deficiencies were identified through observation, interviews, and record review, highlighting failures in both accident prevention during wheelchair transport and supervision of residents at risk for elopement. The lack of adherence to established safety protocols and failure to follow facility policy directly contributed to resident injury and unauthorized exit from the facility.