Failure to Properly Secure Resident During Transport Resulting in Serious Injury
Penalty
Summary
The facility failed to follow its established procedures for the safe transportation and supervision of a resident, resulting in a significant accident. Specifically, a Licensed Practical Nurse (LPN) who was newly trained and licensed to drive the facility van transported a resident from the emergency room back to the facility. The LPN did not properly secure the resident in the van, only locking the wheelchair wheels and neglecting to use the required securement systems. The LPN admitted to this lapse, stating that he believed the short distance justified the omission. As a result, when the van accelerated from a stop, the resident rolled backward and fell, striking his head on the rear door of the van. The resident involved had a complex medical history, including a left above-knee amputation, hemiplegia, diabetes, dementia, and a history of falls, and was identified as being at high risk for falls and injury. Following the incident, the resident was diagnosed with a left subdural hematoma and a minimally displaced left scapular fracture. Documentation and interviews confirmed that the LPN had received training on securing residents but failed to implement these procedures during the transport, directly leading to the resident's injuries.