Failure to Maintain Safe Transport and Fall Prevention Practices
Penalty
Summary
The facility failed to maintain transport equipment in working order and did not ensure the safe and proper securing of a resident during van transport. One resident, who was cognitively intact but physically dependent and classified as high fall risk, was transported in a facility van with a seatbelt that was not properly attached to the floor anchor. The staff member responsible for securing the resident did not verify the functionality of the seatbelt or the anchor, resulting in the resident falling from the wheelchair during transport. The fall led to significant injuries, including a forehead hematoma, multiple facial lacerations requiring sutures, and bilateral nasal bone fractures. The van's equipment was later found to have stiff, loose, and aged lap belts, with a faulty anchor that contributed to the incident. Additionally, the facility failed to implement and update fall interventions and did not conduct root cause analyses for multiple falls experienced by another resident. This resident, who had significant cognitive and physical impairments and was classified as high fall risk, experienced several unwitnessed falls while attempting self-transfers. Despite repeated incidents, the facility did not document root causes for these falls or update the care plan with appropriate interventions. Staff were observed transferring the resident without required assistance, mechanical lift, or gait belt, and the resident's wheelchair was not adjusted as specified in the care plan. Personal alarms and other interventions were also not in place as directed. The facility's own policy requires individualized interventions, hazard analysis, and root cause identification for all residents at fall risk. However, documentation and investigation of falls were insufficient, lacking necessary details to determine causes and prevent recurrence. The failure to maintain equipment, ensure proper supervision, and follow established protocols directly contributed to the injuries and repeated falls experienced by the residents.