Failure to Secure Resident in Van Results in Injury
Penalty
Summary
A deficiency occurred when a resident was transported in the facility van without proper use of vehicle safety restraints, as required by the facility's Motor Vehicle Safety Program. The program specifies that seat belts and shoulder harnesses must be used whenever the vehicle is in operation, and the vehicle should not move until all passengers are properly restrained. On the day of the incident, the resident, who uses a manual wheelchair and requires supervision for transfers, was loaded into the van by a Certified Nurse's Assistant (CNA) and accompanied by a Licensed Practical Nurse (LPN). Neither staff member secured the resident's wheelchair or provided a seatbelt before transport. During the drive, after stopping at a red light, the CNA accelerated the van, causing the resident's wheelchair to flip backwards. The resident fell, striking his head and experiencing immediate pain in the neck, head, and chest. The LPN and CNA assisted the resident back into the wheelchair and completed the transport back to the facility. The resident, who has diagnoses of dementia, major depression, and obesity, reported ongoing pain following the incident, which was not present prior to the fall. Subsequent medical evaluation revealed a closed head injury and a non-displaced acute fracture of the left sixth rib. The resident required increased pain management, including the addition of new medications. Both the CNA and LPN involved in the transport stated they had never received training on how to properly secure residents in wheelchairs in the facility van. The Director of Nursing confirmed that the failure to secure the resident led to the accident and resulting injuries.