Universal Health Care Lillington

LILLINGTON, NC Resident moved by staff member after falling out of wheelchair in van accident dies at hospital.

UNIVERSAL HEALTH CARE LILLINGTON

FACILITY FAILED TO PROVIDE APPROPRIATE TREATMENT AND CARE ACCORDING TO ORDERS, RESIDENT’S PREFERENCES AND GOALS.

State Findings:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, staff and Medical Doctor interviews, the facility failed to evaluate a resident’s condition by a licensed professional before moving a resident following a fall in the facility’s transport van for 1 of 2 residents sampled for assessment after an accident (Resident #1). Resident #1 experienced a Cervical (C2-C3) fracture to the neck and expired at the hospital.

Review of a Witness Interview Form dated [DATE] and signed by TA #1’s Supervisor (who was over medical records and transportation scheduling) revealed a call came to her on [DATE] at 5:24 PM from TA #1 who said Resident #1 had fallen out of his wheelchair. He said a vehicle had cut him off and he had to slam on the brakes causing Resident #1 to hit the van floor. TA #1 said, the resident was strapped in, but not sure how it came loose. He said Resident #1 was bleeding around the head area. I told him to call 911. I called the DON and told him what had happened. The DON said, we have to go get the van because TA #1 cannot drive the van. When we (DON and I) arrived at the station, the paramedics were already there assessing Resident #1. The DON walked on the driver side of the van to see what was going on with Resident #1. I looked at Resident #1, knowing that he had just completed his [MEDICAL TREATMENT] treatment and saw that his eyes appeared weak/sleepy-like and blood covering his bottom teeth. He looked to me and was trying to say something, but his words were not clear. At approximately 6:00 PM, Resident #1 was transported to the local hospital.

Review of a Certificate of Death with date of death of [DATE] revealed Resident #1’s immediate cause of death was multiple [MEDICATION NAME] force injuries. Description of how injury occurred revealed motor vehicle stopped abruptly throwing unrestrained passenger forward.

During an interview with the Administrator and the Executive Director on [DATE] at 12:32 PM they confirmed TA #1 should not have moved Resident #1 following the incident on [DATE] prior to being assessed by a licensed staff member or EMS. The administrator and Executive Director provided the following plan of correction with a compliance date of [DATE].

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