Failure to Properly Secure Resident in Transport Van Results in Injury
Penalty
Summary
A deficiency occurred when a resident was not safely secured in a facility transportation van according to the manufacturer's instructions during a trip to a medical appointment. The resident, who had a history of stroke with right-sided hemiparesis, end-stage renal disease requiring dialysis, and was dependent on staff for transfers and wheelchair mobility, was being transported by a facility driver. During the trip, the driver made an abrupt stop to avoid a collision, causing the resident to slide out of her wheelchair, with her left foot becoming wedged under the driver's seat. The driver stopped the van, repositioned the resident, and continued to the hospital. Upon arrival, the resident had again slid out of the wheelchair, with her back against the wheelchair legs and the rest of her body on the van floor. The manufacturer's instructions for the van's securement system specified that the lap and shoulder belts should be positioned directly against the passenger's body, not obstructed by wheelchair components such as armrests, and should be worn low across the pelvis. However, during a reenactment, it was demonstrated that the lap/shoulder belt had been placed over the wheelchair's armrest, preventing it from being firmly pressed against the resident's lap. This improper securement allowed the resident to slide out of the wheelchair during sudden vehicle movement. Staff interviews and observations confirmed that the resident was not secured per the manufacturer's guidelines, and the armrest of the wheelchair interfered with proper belt placement. As a result of the improper securement, the resident suffered a nondisplaced trimalleolar fracture of the left ankle, which required a splint and opioid medication for pain management. The incident was documented in medical records, and interviews with staff, the resident, and the physician confirmed the sequence of events and the resulting injury. The deficiency affected one of three residents reviewed for accidents.