Failure to Properly Secure Wheelchair During Resident Transport
Penalty
Summary
A deficiency occurred when a resident's wheelchair was not properly secured during transportation in the facility van, resulting in the wheelchair tipping backward and the resident sustaining injuries. The incident took place while a CNA was driving the van, accompanied by the Activities Director and the resident. During the return trip from an outing, the resident's wheelchair rolled backward, causing the resident to hit the back of their head on the lift rack. The resident was transported to the emergency room for evaluation and treatment, where injuries including a bump on the back of the head, bruising, and swelling were documented. The resident involved was cognitively intact and had multiple diagnoses, including a thigh bone fracture, worn cartilage, anxiety, diabetes, and muscle wasting. The resident used a wheelchair or walker for mobility. Documentation and interviews revealed that the CNA had attended in-service training on proper lift operation and securing residents, and that the wheelchair had been strapped in with a seatbelt and tie-downs before departure. However, a subsequent inspection by a van safety company found that the tie-downs (retractors) were not in the proper position to secure the wheelchair, which could allow for tipping or side-to-side movement. The inspection also noted that the way the retractors were positioned would not have allowed them to be tight enough to prevent the incident. Interviews with staff and the inspection company confirmed that the tie-downs were not correctly placed at the time of the incident. The Activities Director and CNA both reported that all straps and belts appeared to be in place after the incident, but the inspection company clarified that the retractors were not in the correct position to safely secure the wheelchair. The facility did not have a specific policy for accidents at the time of the event.