Failure to Safely Transport Resident and Complete Fall Investigations
Penalty
Summary
The facility failed to ensure safe transport and adequate supervision for a resident with Alzheimer's disease, adult failure to thrive, rhabdomyolysis, and gait abnormalities, who was identified as a high fall risk. The resident experienced three falls in one month, two of which occurred during transport in a wheelchair when staff members pushed the resident forward despite her leaning forward and attempting to stand. Both CNAs involved confirmed that the resident frequently leaned forward and tried to stand while seated, and that they proceeded with transport under these conditions, resulting in the resident falling forward out of the wheelchair. One of these falls resulted in a hematoma to the resident's forehead. Additionally, the facility did not complete required fall investigations for two of the resident's falls, as mandated by their Accidents and Incidents Policy. The Director of Nursing confirmed that staff should not have transported the resident while she was leaning forward or attempting to stand, and acknowledged that fall investigations were not conducted for two incidents. These failures affected one resident reviewed for falls out of a sample of 31.