Failure to Monitor Infection and Ensure Safe Transport for Resident with Mobility Impairments
Penalty
Summary
The facility failed to monitor for signs and symptoms of infection for a resident who was at risk due to refusal of vaccinations and had a history of cerebral palsy and elevated white blood count. The resident developed redness, swelling, and pain in the right eye, which was identified as possible cellulitis. Orders were given for oral and eye drop antibiotics, and staff were instructed to mark the area of redness and monitor for spread. However, there was no consistent daily or shift-based documentation or comprehensive assessment of the infection from the time antibiotics were started through the following week, as confirmed by multiple staff interviews and review of the electronic health record. The lack of monitoring was acknowledged by the LPN, ADON, DON, and the nurse practitioner, all of whom stated that regular assessments should have been performed and documented to detect changes in the resident's condition. Additionally, the facility failed to ensure safe transportation for the same resident to an outside appointment. The resident, who normally used a specialized electric wheelchair due to immobility from cerebral palsy and scoliosis, was transferred to a manual wheelchair for transport because the facility van could not accommodate the electric wheelchair. The resident was left unattended in the manual wheelchair at the clinic for approximately 20 to 25 minutes, during which time he was unable to move himself or seek assistance due to lack of core strength. The family member and staff interviews confirmed that the resident was not assessed for safety in a manual wheelchair prior to transport, and the director of therapy expressed concern about the lack of such an assessment given the resident's physical limitations. Communication failures also contributed to the incident, as the transport driver was not provided with proper paperwork or clear instructions regarding the resident's destination, resulting in the resident being left at the wrong location. The family member was not immediately informed of the resident's whereabouts, and facility staff were unaware that the resident had been left unattended. Facility policies for infection monitoring and safe transport were requested but not provided for review.