F0689

J

Failure to Secure Wheelchair and Resident During Transport Results in Serious Injury

Monroe, North Carolina Survey Completed on 04-17-2025

Penalty

Fine: $16,985

Summary

A facility failed to ensure the safe transport of a resident with severe cognitive impairment and mobility limitations following an orthopedic appointment. The designated van driver did not properly secure the resident's wheelchair to the van floor or ensure that the resident was restrained according to the manufacturer's instructions. Specifically, the driver did not tighten the tie-down straps, did not verify that the lap and shoulder belts were fully engaged, and did not check the security of the wheelchair or restraints before departure. The driver later admitted to rushing and skipping these safety checks due to time constraints.

During transport, after making a right turn onto a main road, the resident and her wheelchair tipped over, resulting in the resident falling onto the van floor. The driver found the resident with a bleeding head laceration, the wheelchair tipped on its side, the seat and lap belt disconnected, and one of the front tie-down straps unhooked. Emergency medical services were called, and the resident was transported to the emergency department, where she was diagnosed with a frontal scalp laceration, a left middle finger fracture, and a cervical spine fracture. The incident was directly attributed to the failure to secure the wheelchair and occupant per the manufacturer's guidelines.

Interviews and reenactments with facility staff and the van driver confirmed that the required safety procedures were not followed. The driver demonstrated during reenactments that she did not tighten the tie-downs or check the restraints for proper engagement. Staff interviews and medical records indicated that the resident was unable to stand or transfer independently, further emphasizing the necessity of proper securement during transport. The facility's failure to ensure adherence to safety protocols resulted in significant injury to the resident.

Removal Plan

• Resident was assessed and transported to the emergency department for evaluation and treatment after the incident.
• The Van Driver was suspended pending the results of the investigation.
• The facility notified the resident’s legal guardian and Medical Director of the incident.
• A reenactment of the incident was conducted with facility leadership to determine how the wheelchair was secured.
• The facility’s van driver education records were audited to ensure the Van Driver received necessary education and training.
• The Director of Nursing reviewed facility incidents and accidents to ensure no other falls/incidents had occurred related to van transport.
• An audit of all appointments via van transport was completed to ensure residents were rescheduled with a contracted wheelchair transport company and that residents and/or responsible parties were notified.
• All appointments requiring van transportation were reviewed during the center’s morning clinical meeting to verify transfer vehicle and resident/responsible party notification.
• An audit was completed to identify any interviewable residents that were transferred to ensure no incident or accident occurred during their van transport.
• The contracted wheelchair transport company’s staff training and certification were reviewed and validated to be in place before use.
• The facility van was sent to the wheelchair transport van service center for inspection; no problems were found.
• All transport appointments requiring the facility van were scheduled through a contracted wheelchair transport company.
• The facility contracted all resident van transports with a contracted wheelchair transport company.
• All appointments requiring van transportation were reviewed in the morning clinical meeting to determine if additional assistance was necessary.
• The Administrator received education on checking the locking mechanisms/restraints on the van for the wheelchair and seatbelt prior to transporting residents per manufacturer’s instructions.
• The Administrator provided education to the Maintenance Director and Director of Nursing regarding van safety and checking locking mechanisms/restraints per manufacturer’s instructions.
• The facility will continue to use the contracted wheelchair transport company instead of transporting residents in the facility van.
• An ADHOC quality assurance (QA) meeting was held to review the incident and identify the root cause.
• An audit will be completed of two residents receiving transport services by the Administrator twice a week to ensure the contracted wheelchair transport company is compliant with safety guidelines.
• Once a new van driver is identified, they will go through the facility’s motor vehicle and driver safety program, including a return demonstration and education/training by the Administrator and President of Operations.
• The Quality Assurance Improvement committee will review the results of the weekly audits during monthly QA meetings to determine if further actions are needed.
• The Administrator and Director of Nursing are responsible for ensuring implementation of the immediate jeopardy removal and that education and training are provided.