Failure to Properly Secure Wheelchair During Transport Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a wheelchair-bound resident, who was dependent on staff for mobility and positioning due to bilateral below-the-knee amputations and other significant medical conditions, was not properly secured during transportation in the facility's van. The van driver failed to anchor the resident's wheelchair and did not apply the necessary restraints. As a result, when the van accelerated, the wheelchair tipped backward, causing the resident to fall onto the floor with the wheelchair landing on top of her. The incident resulted in the resident sustaining multiple serious injuries, including fractures of the cervical and thoracic vertebrae, multiple rib fractures, an epidural hemorrhage, and significant pain, requiring hospitalization in the ICU. Interviews and record reviews confirmed that the resident reported not feeling properly secured in the van and recounted that the driver had previously driven erratically. Another resident also reported that the same van driver had not anchored her wheelchair or applied seatbelts during transportation. Staff interviews revealed that proper procedures for securing wheelchairs included anchoring at four points and using both a lap seatbelt and a shoulder strap, but these procedures were not followed by the van driver involved in the incident. The facility's investigation noted that the van and its equipment were inspected and found to be functioning properly, indicating that the failure was due to staff action rather than equipment malfunction. The van driver was unable to confirm whether the wheelchair had been anchored prior to departure, and the facility was unable to determine how the incident occurred if the wheelchair had been properly secured. The resident required a rigid cervical collar and additional support following the incident, and her care plan was updated to reflect her new needs.