Failure to Properly Secure Resident in Wheelchair During Van Transport
Penalty
Summary
A deficiency occurred when a resident was not properly secured in a wheelchair during transport in the facility van, resulting in the wheelchair tilting backwards while ascending a steep hill. The resident, who had diagnoses including heart failure, hypertension, diabetes mellitus, depression, and chronic pain, was cognitively intact and required supervision or assistance with activities of daily living and mobility. During the incident, only three q-straints were used to secure the wheelchair, although the van was typically equipped with four. The staff member responsible for transport did not receive training or have access to a checklist or user manual for securing wheelchairs in the van, and was unaware of the missing fourth q-straint prior to the trip. The staff member transporting the resident noticed the wheelchair tipping back after the resident called out, prompting the staff to pull over and readjust the restraints. It was observed that the front wheels of the wheelchair were off the floor and the back was not properly secured, which contributed to the instability. The staff member later reported the incident to the DON and provided a written statement, but there was no documentation in the resident's chart, no incident report, and no follow-up recorded regarding the event. Further investigation revealed that the facility lacked policies, procedures, or guidelines for securing residents in the van with q-straints, and there was no evidence of staff education or competency checks related to this process. The administrator was unaware of the incident until informed by surveyors and confirmed the absence of relevant documentation, training materials, or a user manual for the van's restraint system.