Keeping residents safe while on the go

Nursing Homes, June, 2005 by Linda Williams

When you think of resident deaths and injuries associated with nursing home staff negligence, transportation safety probably doesn't come to mind. Yet every year residents are injured needlessly by accidents that occur during transport--often within sight of the facility. Unfortunately, most of these accidents could be avoided if simple precautions are followed. It's one of those commonsense risk exposures that administrators may have a false sense of control over, until it happens to one of their residents. Please take the time to review the circumstances surrounding the following case and make changes as appropriate at your facility.

The Situation

An 89-year-old woman was admitted to a nursing facility with a history of severe degenerative arthritis, congestive heart failure, hypothyroidism, depression, renal failure, asthma, anxiety, and obesity. The woman required the use of a Foley catheter and was dependent on staff to propel her in a wheelchair. She was alert and oriented and could effectively communicate her wants, needs, and concerns to staff members.

Within a few months, the woman developed a significant cough with congestion and was transported to the hospital by ambulance. At the hospital, x-rays indicated she had developed pneumonia and marked diffuse osteopenia, which left her bones brittle. She was successfully treated with antibiotics and returned to the facility, but she continued to have sporadic upper respiratory infections.

Over time, the woman developed a habit of leaning forward whenever she sat for long periods of time in her wheelchair. Her leaning contributed to several falls during the next four years. Fortunately, she was never seriously injured and always expressed an understanding when cautioned by staff about the dangers of leaning forward in her wheelchair. To minimize her need to lean, the staff made efforts to make items readily accessible to her while in her wheelchair. A "lap buddy" was even used on occasion.

[ILLUSTRATION OMITTED]

One day, the woman was driven to a podiatry appointment in the nursing facility's van. While returning to the facility, the van driver stopped at a drive-through restaurant to purchase some food for the woman to eat back at the facility. As the driver drove across a bridge nearing the facility, she heard the woman cry out that she was slipping from her wheelchair. By the time the driver could pull the van over, the woman had already fallen to the floor of the van.

Fortunately, the driver was able to obtain the assistance of two delivery men to return the woman to her wheelchair. The woman's knees were scraped, but she thought she would be all right, so the driver drove her back to the facility where she was subsequently placed in bed. After consuming the take-out food, the woman began to complain of bilateral knee pain, as her knees began to noticeably swell. Mobile x-rays were taken, which indicated possible fractures. The woman was immediately transported to the hospital emergency room, where arrangements were made for her granddaughter to meet her.

At the hospital, the woman and her granddaughter were told that she had sustained bilateral tibia and fibula fractures. An orthopedic surgeon was consulted who felt that surgical intervention was not a viable option and recommended a course of bed rest and pain medication. Over the next few days, the woman suffered a marked decline in her respiratory abilities. She was not placed on any machines, because of her DNR status, and instead was treated with intravenous fluids, antibiotics, and a diuretic.

During her hospital stay, a sputum culture and sensitivity test indicated that the woman had developed an upper respiratory infection of Staphylococcus aureus, pneumonia, and a urinary tract infection of E. coli, Pseudomonas aeruginosa, and MRSA. The physician adjusted her antibiotics in response to these lab findings. After discussing the woman's condition with her granddaughter, the physician directed the hospital staff to provide comfort measures only. The woman passed away five days after the accident. The cause of death listed on her death certificate was cardiopulmonary arrest, congestive heart failure, and hypothyroidism.

The nursing facility staff were devastated by the incident. The administrator reported it to the state regulating authority, which launched an immediate investigation. The driver told the state investigators that she was substituting for the person who normally drove the van, who was out sick on the day of the incident.

The driver said the woman's wheelchair was fastened to the floor of the van in the appropriate manner. When the woman fell, the wheelchair remained secure, but the lap buddy that she used to secure the woman to the wheelchair had come undone because of her pressing weight and forward movement. The driver stated that she applied the lap buddy across the woman's waist and around the arms of the wheelchair before securing it in the back of the wheelchair. Because of the woman's size, the driver was not able to tie a complete knot at the back of the wheelchair.