Resident Fall Due to Unsafe Food Cart Handling
Penalty
Summary
Staff failed to safely maneuver a food service cart, resulting in a resident fall with injury. The resident involved had diagnoses including dementia, glaucoma, and schizoaffective disorder, and was care planned to ambulate independently with a cane but required supervision due to severe cognitive impairment. On the day of the incident, the resident exited their room as a food service cart was being pushed down the hallway. The resident's cane came into contact with the bumper of the cart, causing the resident to lose balance and fall onto their left side. The staff member pushing the cart reported checking both sides for residents but was unable to see over the cart, and did not see the resident exiting the room before the collision occurred. The fall resulted in a left femoral fracture, requiring hospital transfer and surgical intervention. Prior to the incident, the resident had no history of falls. The facility's policy directed staff to make the environment as free from accident hazards as possible, but the staff member was unable to ensure the pathway was clear due to the size of the cart and limited visibility. The deficiency was identified through observations, interviews, and review of clinical records and facility documentation.