Failure to Secure Wheelchair Residents During Van Transport Due to Faulty Straps and Lack of Staff Training
Penalty
Summary
The facility failed to ensure that residents who required wheelchair transport were safely and properly secured during van transportation. On multiple occasions, staff transported residents using a facility van with malfunctioning wheelchair straps, with only two out of four straps functional. During one incident, a resident with end stage renal disease, hemiplegia, and impaired mobility was transported to and from dialysis with only two straps securing the wheelchair. On the return trip, one strap came loose while navigating a roundabout, causing the resident's wheelchair to tip backward, resulting in the resident hitting their head and sliding to the floor of the van. The resident sustained a bump and scratch to the head and later experienced a sudden loss of vision, prompting a hospital evaluation. Prior to this incident, residents had repeatedly voiced concerns about the condition of the van seatbelts and the lack of proper securing during transport in Resident Council meetings. Documentation showed that these concerns were either not addressed, inadequately documented, or not communicated back to residents. Maintenance logs did not reflect any work orders or repairs for the van straps or seatbelts, and there was no evidence of routine checks or a manufacturer's manual for the equipment. Staff interviews revealed a lack of training on how to properly secure wheelchairs in the van, and some staff believed that certain types of wheelchairs did not require strapping. Additionally, unlicensed staff were involved in transporting and assisting residents after accidents occurred. Multiple residents reported feeling unsafe during van transport, with some stating they had to hold onto bars or seats to prevent movement due to loose or missing straps. Staff acknowledged ongoing issues with the straps, but no formal maintenance requests were made, as it was assumed that everyone was aware of the problem. The facility did not provide a policy or training for staff responsible for transporting residents, and there was confusion among staff regarding responsibility for assessing and maintaining the safety of the van's securing mechanisms.