Failure to Secure Wheelchair During Transport Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to secure a resident's wheelchair with the appropriate safety belts during transport in the facility van. The facility's policy required the use of wheelchair securement systems, including lap and cross-body safety belts and floor anchorages, to ensure safe transportation. However, the staff member responsible for transporting the resident did not properly fasten the wheelchair to the van's safety belts and did not position the wheelchair correctly inside the van. As a result of this failure, the resident's wheelchair tipped over during transport, causing the resident to fall to the floor of the van. The resident sustained multiple head lacerations, which required staples, and a nondisplaced sternal fracture. The incident was discovered when the resident arrived at the emergency room with injuries, as the van driver did not notify the facility immediately after the event. The resident involved had been admitted with medical diagnoses including heart failure, COPD, and chronic kidney disease, and was cognitively intact at the time of the incident. The van driver later confirmed in a written statement that the seatbelt had not been used and the wheelchair had not been properly secured. Inspection of the van after the incident confirmed that the floor stabilizers and lap belt had not been affixed.