Failure to Secure and Supervise Wheelchair-Bound Resident During Transport
Penalty
Summary
The facility failed to ensure a resident received adequate supervision to prevent accidents during transport, resulting in a serious incident. A cognitively intact male resident, who was blind and dependent on a wheelchair for ambulation, was being transported back to the facility after dialysis. The CNA responsible for transport did not secure the resident's wheelchair with the van lift strap while the lift was in use. The CNA pushed the resident onto the lift, activated it, and rode with the resident to the top. The CNA then stepped inside the van, leaving the resident unattended on the elevated lift platform. The resident, still in his wheelchair, rolled off the back of the lift and fell approximately 3 to 3.5 feet onto the parking lot pavement below. Eyewitness accounts and video footage from the dialysis center confirmed that the resident was left unattended on the lift and was not properly secured. The incident occurred in cold, wet, and snowy conditions, and the resident was not dressed for the weather, landing in a puddle after the fall. The facility's own policy required that wheelchair brakes be set and the lift safety restraint fastened, but the CNA did not follow these procedures. The van's lift was found to be functioning properly, and the safety barrier was operational at the time of the incident. As a result of the fall, the resident sustained multiple fractures to his thoracic spine, specifically at T4 and T5, and was hospitalized in the intensive care unit. Medical records indicated the resident had significant comorbidities, including diabetes, chronic kidney disease requiring dialysis, muscle weakness, and visual impairment. The resident's condition was critical following the incident, with ongoing pain and loss of independence. Interviews with facility staff and the resident's responsible representative confirmed that the resident was not secured on the lift and was left without supervision at a critical moment, directly leading to the accident and subsequent injuries.