Failure to Ensure Resident Safety During Transportation and Fall Prevention
Penalty
Summary
The facility failed to ensure resident safety during facility-provided transportation and did not implement required fall interventions for residents at risk for falls. One resident, who was dependent on staff for transportation and had a history of cerebral infarction, generalized weakness, and was on blood thinning medication, was injured during transport when the transport aide did not properly secure the wheelchair straps. As a result, the resident was dislodged from the wheelchair during a bus turn, fell, and sustained a head laceration that required medical treatment, including staples. The resident reported that only one side of the wheelchair was locked, and despite questioning the aide, was assured everything was secure. The incident was confirmed by interviews and documentation, and the resident expressed fear and pain following the event. Another resident, with diagnoses including hypertension, diabetes, and end-stage renal disease, experienced two falls and was identified as being at risk for further falls. The care plan for this resident included specific interventions such as 15-minute checks, traction strips to the floor, and ensuring the call light was within reach. However, during observation, the resident's call light was not accessible, and traction strips were not present as ordered. The resident stated she relied on her roommate to call for assistance, indicating that the prescribed interventions to prevent falls were not in place at the time of review. Policy review indicated that the facility was required to assess each resident's fall risk and implement appropriate interventions, including environmental modifications and care planning. Despite these requirements, the facility did not ensure that interventions were consistently implemented for residents at risk for falls or that transportation safety protocols were followed, resulting in actual harm to at least one resident and placing others at risk.