Failure to Ensure Safe Transportation for Dependent Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure safe and quality transportation for a resident with a fractured right femur, dementia, and morbid obesity, who was non-weight bearing and dependent for transfers and mobility. The resident required a mechanical lift for transfers and total assistance for locomotion, as documented in her care plan. On the day of the incident, the resident was transported to a medical appointment without a facility staff escort, despite her significant care needs and cognitive impairment. During transport, the resident slid down in her wheelchair, causing her immobilized, fractured leg to come off the foot pedals and drag on the ground. The mat used to connect her foot pedals became dislodged, contributing to the incident. Multiple witnesses, including the resident, reported that she was in significant pain and was crying and screaming during the transport. Upon arrival at the doctor's office, staff there had to assist in repositioning her, and due to her distress and the incident, an X-ray was ordered and she was transported by ambulance to the hospital. The facility's policy requires that residents needing assistance, such as those with impaired decision-making or requiring help with activities of daily living, must have an appropriate escort during transport, which was not arranged in this case.