Failure to Ensure Safe Transport and Timely Reporting After Resident Fall in Vehicle
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision to prevent an accident for one cognitively intact, highly dependent resident during transport to a medical appointment. The resident had significant respiratory and oncologic conditions, including COPD with acute exacerbation, acute and chronic respiratory failure with hypoxia and hypercapnia, emphysema, malignant neoplasm of the right upper lobe of the lung, and shortness of breath. The resident’s MDS documented that he was dependent for functional abilities, always incontinent of bowel and bladder, and had a history of one fall with major injury. Care plans in effect included staff assistance with wheelchair safety every shift and education of the resident and family on fall reduction strategies. On the morning of the incident, nursing documentation showed that the resident was assessed prior to departure for a scheduled oncology appointment and was found to have stable vital signs, even and unlabored respirations, no shortness of breath or distress, and no complaints of pain or discomfort. The resident was transported from his room to the facility’s transport vehicle by the facility’s transport driver. The driver reported placing the resident in his wheelchair on the vehicle lift, raising him into the vehicle, and securing the wheelchair with four straps anchored to the floor and a belt around the resident’s waist secured to the wheelchair before beginning the drive to the appointment. While en route and approximately a block or about a minute away from the appointment destination, the driver heard a noise from the back of the vehicle and, upon looking back, saw the resident lying on his left side on the floor of the vehicle, still in his wheelchair. The driver stopped the vehicle, went to the back, unhooked the seatbelt around the resident’s waist, left the resident on the floor while he placed the wheelchair back in an upright position, then lifted and repositioned the resident into the wheelchair and re-secured him in the same manner as at the start of the trip. The driver did not observe visible injuries and the resident denied pain at that time. The driver then continued the trip and delivered the resident to the appointment, where the resident’s son was present. The driver informed the son of the fall; the son checked the resident, the resident again stated he was okay, and the son told the driver it was acceptable for him to leave. Later that day, the resident’s son reported to facility nursing staff that the resident had fallen in the transport vehicle and that, after the appointment, the resident had been sent by ambulance from the appointment site to a hospital, then transferred to another hospital, where he was found to have a rib fracture and pneumothorax. Nursing documentation that evening recorded that the resident had departed that morning in stable condition and that the son reported the fall in the vehicle and subsequent hospital evaluation. The resident’s later diagnoses included traumatic pneumothorax, traumatic hemothorax, and multiple right-sided rib fractures with routine healing. The transport driver acknowledged that he did not report the fall to the facility upon returning from the trip and only made a report the following day after being contacted by the facility. The resident, interviewed by telephone from the hospital, confirmed that he had been properly strapped in with four straps and a waist belt, that the vehicle came to a stop near the destination and he fell backward in his wheelchair, and that the driver repositioned him and continued to the appointment. Despite these accounts and the resident’s significant medical vulnerabilities, the facility failed to ensure that the transport process and subsequent communication and assessment fully protected the resident from accident and injury during and immediately after the fall event.
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