Failure to Assess Home Environment and Supervise High-Fall-Risk Resident During Transport Visit
Penalty
Summary
Failure to assess safety risks and provide adequate supervision occurred when the facility transported a resident with a history of repeated falls and impulsive behavior to her apartment without ensuring a safe environment or appropriate staff support. The resident had diagnoses including repeated falls, CKD, bipolar disorder, anxiety, major depression, and intrahepatic bile duct cancer, and was documented as alert and oriented but impulsive. Her care plan interventions included keeping the environment free from clutter, reinforcing use of assistive devices, observing for unsteady gait and balance, and instructing her to avoid sudden position changes. Physical therapy records showed she required a front-wheeled walker and contact guard assist for ambulation, and occupational therapy did not recommend ambulation without assistance. Despite this, the Transportation Director, who was not currently certified, transported the resident to her apartment with the expectation from the Administrator that the resident would remain in her wheelchair during the visit. During the home visit, the resident chose to use her walker in the apartment and left her wheelchair in the hallway. The Transportation Director reported the apartment was unsanitary, with dried feces, gloves, and empty packages on the floor from a previous EMS call, and the Administrator confirmed the apartment had not been assessed for safety prior to the visit. While the resident was sitting in a recliner sorting papers, the Transportation Director began moving boxes away from the bedroom doorway at the resident’s request. The resident then stood up, took a few steps without using her walker, and fell, sustaining a laceration above her right brow that required EMS transport to the emergency room. The facility’s own Transportation Policy stated it was responsible for ensuring any resident transported by facility vehicle would have a safe and secure transport, and the Administrator verified that a certified/licensed staff member had not been sent along with the transportation driver for this visit.
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