Failure to Properly Secure Wheelchair During Resident Transport
Penalty
Summary
A deficiency occurred when a certified nursing assistant/transport driver failed to properly secure the front straps of a resident's wheelchair during transport in the facility's van. As a result, the wheelchair tipped over backwards when the van accelerated after a stop, causing the resident to fall and strike the back of his head. The facility's policy required that wheelchairs be properly secured with securement equipment, and staff interviews confirmed that the wheelchair was not secured according to these guidelines. The resident involved had significant medical conditions, including end stage renal disease, peripheral vascular disease, cognitive communication deficit, and a right above knee amputation. He was also prescribed blood thinning medications, which increased his risk for serious injury following a head trauma. Due to the incident, the resident was transported to a local emergency department for evaluation of a head injury and was unable to receive his scheduled dialysis treatment.