Failure to Prevent Accident During Resident Transport
Penalty
Summary
The facility failed to ensure adequate supervision and prevent an avoidable accident when a resident with moderately impaired cognition, as indicated by a Brief Interview for Mental Status Summary score of 8 and a diagnosis of encephalopathy, was transported in the facility van. During the return trip from a doctor's appointment, the resident repeatedly unfastened his seatbelt and expressed a desire to go home with his sister. The certified nurse aide (CNA) driving the van stopped to refasten the seatbelt and encouraged the resident to remain secured, but the resident continued to remove the belt. On the second occasion, the resident fell from his wheelchair to the floor of the van. The CNA assessed the resident after the fall and returned him to his chair, then continued driving to the facility, where the incident was reported to nursing staff. Upon arrival, the resident was found to have an abrasion over his left eye and was sent to the hospital as a precaution. Interviews with facility leadership acknowledged that the resident's behavior of repeatedly unfastening his seatbelt contributed to the incident, and that the safest action would have been to stop transport and request assistance after the initial unfastening. However, the CNA continued transport after the fall, and the incident was only reported upon arrival at the facility.