Failure to Secure Resident During Van Transport Results in Multiple Fractures
Penalty
Summary
A deficiency occurred when a transport driver (TD) failed to ensure the safe transport of a resident with severe cognitive impairment, morbid obesity, and muscle weakness. The resident, who was dependent on staff for all activities of daily living and wheelchair mobility, was transported in a facility van without a seatbelt. The TD was unable to secure the seatbelt due to the resident's size and, based on previous guidance from a former administrator, believed that securing only the wheelchair was sufficient for safety. During the transport, the resident slid out of the wheelchair and ended up on the floor of the van. Following the incident, the resident was initially evaluated at a clinic where only a hip x-ray was performed and no injuries were identified. However, over the next several days, the resident experienced increasing pain in both legs and hips, as well as visible bruising. The resident was eventually sent to the emergency department, where closed fractures of both tibias and the left femur were diagnosed. The resident required pain management and immobilization of both legs as a result of these injuries. Interviews with facility staff revealed that the TD had not received specific training on the transport of residents or the use of restraints in the facility van. The human resources director confirmed that no policies, procedures, or training related to resident transport had been provided. Facility policy required that all residents and wheelchairs be safely secured during transport, but this was not followed in the incident, leading to the resident's injuries.