Failure to Secure Wheelchair in Transport Van Results in Resident Injury
Penalty
Summary
A deficiency occurred when a contracted transport driver failed to secure a resident's wheelchair in accordance with the manufacturer's instructions prior to departing from a dialysis clinic. The wheelchair was not attached to the van's floor securement system, which resulted in the wheelchair flipping backwards during transit. The resident, who remained in the wheelchair, struck her head and back on the van floor, leading to immediate and severe pain. The resident involved had a history of left above-the-knee and right below-the-knee amputations, was dependent on dialysis, and had severe cognitive impairment, requiring staff assistance for transfers and wheelchair mobility. Prior to the incident, the resident's pain was managed with PRN ibuprofen and tramadol, and she was not coded for pain or opioid use on her most recent assessment. On the day of the incident, the resident returned from dialysis reporting severe pain, and staff observed her moaning, crying out, and unable to sit upright in her wheelchair. She was subsequently transferred to the hospital, where imaging revealed a fracture at the superior endplate of the L1 vertebra. Interviews and documentation confirmed that the contracted transport driver was distracted while loading the resident, failed to secure the wheelchair, and did not report the incident to facility staff. The driver admitted to the error after being contacted by the transportation company. Facility staff, including nurses and nurse aides, noted the resident's distress and pain upon her return, and the incident was reported to the facility's DON and administrator. The event was substantiated through interviews with the resident, staff, and the contracted transportation company, as well as review of medical records and pain assessments.
Removal Plan
- Ceased use of the outside vendor responsible for transportation of Resident #1.
- Identified all residents transported by all transportation providers using the facility transportation calendar.
- Social Worker identified alert and oriented residents on this list using the Brief Interview for Mental Status (BIMS) score of 10 and above.
- Social Services interviewed alert and oriented residents to identify any incident where the transport driver failed to safely secure the wheelchair in the transportation van.
- Facility licensed nurses completed a Skin Note and Pain Assessment for all residents with a BIMS of less than 10 who had transportation to identify potential injury.
- Facility completed investigations and appropriate follow-up action for any concerns identified during interviews and assessments.
- Administrator assumed responsibility to ensure investigations and follow-up were completed.
- Administrator spoke with the Contracted Transportation Company Owner regarding the need for education and documentation.
- Contracted Transportation Vendor provided competency training for all contract transport drivers who transport residents from the facility, including a return demonstration of safely securing a wheelchair.
- Training for contracted transport drivers included the manufacturer's instructional Training Video and return demonstration.
- Training documentation for contracted transport drivers to be provided to the Administrator by the Contracted Transportation Company Owner or Designee and maintained at the facility.
- Newly hired contract transport drivers for this vendor will be provided this training prior to being assigned transportation trips for the facility residents, including a return demonstration.
- Facility's transport drivers received competency training related to securing wheelchairs in the van.
- Facility's transport driver training was provided by the facility Maintenance Director using the manufacturer's instructions and included a return demonstration.
- Newly hired facility transportation drivers will be provided this training and include a return demonstration prior to being scheduled to provide transportation trips, provided by the Maintenance Director.