Resident Left Unattended in Hallway Falls From Wheelchair
Penalty
Summary
The facility failed to ensure adequate supervision and a hazard-free environment when a resident with significant physical impairments was left unattended in a hallway and subsequently fell from her wheelchair. The resident had been admitted with diagnoses including hemiplegia, hemiparesis, type II diabetes mellitus, and muscle wasting and atrophy. After an occupational therapy session, the Occupational Therapist placed the resident in her wheelchair outside her room in the hallway and stated he informed a nurse and a CNA that the resident was in the hallway, but he did not recall whether they acknowledged this information. An IDT note documented that therapy had completed a session with the resident approximately three minutes before the incident and left her in the hallway, endorsed to a nurse who was passing medications at that time. According to interviews, LVN A reported being across the hallway when the OT placed the resident in the hallway and stated she acknowledged when the OT told her the resident was back and had been dropped off in the hallway. LVN A further stated the resident remained in the hallway for about two minutes, during which LVN A turned her back to the resident to speak to another resident in another room. CNA B reported being in another resident’s room when she heard a sound like something hitting the floor; upon checking, CNA B found the resident on the floor on her side facing away from the wheelchair, with the wheelchair tipped on its side. The DON stated that another resident, who was later discharged and unavailable for interview, had witnessed the incident and reported that the resident’s backpack hanging on the back of the wheelchair became caught, causing the wheelchair to tip. Nurse’s notes indicated the resident returned from Good Samaritan Hospital with an abrasion to the left elbow following the fall. The facility’s Resident Rights policy stated that residents are guaranteed certain basic rights, including the right to a dignified existence.
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