Failure to Use Seat Belt During Resident Transport Resulting in Fall
Penalty
Summary
A deficiency occurred when a resident was transported back to the facility after a hospital visit for a suprapubic catheter placement. The staff member responsible for transportation secured the resident's wheelchair to the bus floor but did not fasten the seat belt because the resident complained of pain at the abdominal incision site. Despite the facility's policy requiring seat belts for all passengers, the seat belt was not used. During the return trip, the driver had to brake suddenly for a stopped school bus, causing the resident to lean forward, hit her forehead and face on the seat in front, and slide out of her wheelchair onto the floor. The resident, who had diagnoses including diabetes, obesity, hypertension, anxiety, and depression, required assistance for ambulation and transfers according to her MDS assessment. After the incident, she was found to have an abrasion on her lower back, a pink abrasion on her left knee, and a hematoma on her forehead. The event was witnessed and documented in the nursing progress notes, and the facility's transportation policy requiring seat belt use was not followed during this incident.