Deficiency Due to Inadequate Supervision and Unsafe Ramp Leading to Resident Fall
Penalty
Summary
A deficiency occurred when a resident with significant mobility impairments, including bilateral below-knee amputations, morbid obesity, hemiplegia, and moderate cognitive impairment, was allowed to be pushed in her wheelchair by another resident after a smoke break. The resident's care plan identified her as being at risk for falls due to her medical conditions and specified that she required extensive assistance for transfers and mobility. Despite these documented risks and interventions, the resident was pushed by another resident, with her permission, up a ramp that did not cover the full length of the doorway, resulting in her wheelchair becoming stuck and causing her to fall face-first. Interviews and record reviews revealed that it was common practice for the resident to be pushed by another resident, and staff, including the DON, were aware of this arrangement, citing the resident's right to allow it. The ramp in question was installed by the facility's Maintenance Director at the request of residents, but it did not meet the full width of the doorway, creating a hazard. Staff and other residents reported that the resident was difficult to push due to her weight and that the ramp presented challenges in maneuvering wheelchairs safely. The incident resulted in the resident sustaining a traumatic subdural hemorrhage and requiring hospital transfer. Observations and interviews confirmed that the ramp was a contributing factor to the fall, as it did not provide a safe transition between surfaces. The facility's Life Safety Director later acknowledged that the ramp was improperly installed and created a hazard. Prior to the incident, there was no evidence that the facility had adequately assessed the environmental risks posed by the ramp or enforced supervision and transport protocols to prevent such accidents.