Failure to Secure Resident During Transport and Inadequate Post-Fall Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was properly secured while being transported in the facility’s private vehicle and to follow post-fall assessment procedures before moving the resident. The resident had diagnoses including Multiple Sclerosis and muscle wasting and atrophy, was alert and oriented with a BIMS score of 13, and was able to make her needs known. During transport back from a medical appointment, the CNA driver reported that the resident’s wheelchair was locked in place with a seatbelt secured, and that when the CNA applied the brakes at a red light, the resident slid out of the wheelchair onto the floor of the vehicle, landing on her buttocks. The CNA stated the resident denied pain at that time, was assisted back into the wheelchair, and then transported back into the facility. Upon return to the facility, the resident reported right leg pain. The CNA assisted the resident to bed and notified a nurse of the incident and the complaint of pain. The nurse assessed the resident and observed external rotation and shortening of the right lower extremity, as well as swelling from the right hip to the right thigh. The nurse practitioner’s note documented that the resident reported slipping out of her wheelchair and hitting her head, denied headache, but complained of right hip pain, with the right hip appearing shortened and externally rotated and pain elicited with abduction and adduction. Hospital records later indicated the resident sustained a right intertrochanteric femur fracture requiring surgical repair with intramedullary nailing of the right proximal femur. The resident’s account of the incident conflicted with the CNA’s description of safety measures during transport. The resident stated that the CNA abruptly pressed the brake, causing her to fall forward to the vehicle floor, and reported that her wheelchair was not strapped or properly secured and that no seatbelt was applied. She stated she was sure the wheelchair was not secured because as she fell forward, the wheelchair also moved, tipped over, and hit her on the head. The facility’s Clinical Guideline for Falls Management requires that, prior to moving a resident after a fall, staff assess for injury, perform a pain assessment and physical assessment, and activate emergency response as required, particularly for potential head injury. The Director of Nursing stated that the expectation and facility policy for fall incidents is to report the fall and not move the resident without assessment, especially if the resident is complaining of pain. Despite this, after the fall in the vehicle and the resident’s subsequent complaint of pain, the CNA moved and transferred the resident back to bed before a nurse assessment, contributing to the identified deficiency in accident prevention and post-fall response.
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