Failure to Secure Wheelchair Cushion Leads to Resident Fall During Van Transfer
Penalty
Summary
A deficiency occurred when a resident with a recent below-knee amputation and a history of Type 1 Diabetes Mellitus was not safely transferred from a facility van. The resident, who was cognitively intact, returned from a medical appointment and was being assisted by a staff van driver. During the transfer, as the wheelchair was being maneuvered down the ramp, the resident leaned forward and slid out of the wheelchair, landing on his recently operated stump. The cushion, which was intended to prevent skin breakdown, was not properly secured to the wheelchair and slid out with the resident. Multiple staff interviews confirmed that the cushion's securing strap was not buckled, allowing it to move from its position due to the smooth surfaces of both the cushion and the wheelchair seat. The incident resulted in the resident experiencing significant pain and requiring ambulance transport to the hospital, where he was diagnosed with a fall from the wheelchair and dehiscence of the surgical wound on his stump. Facility documentation and staff interviews consistently indicated that the failure to properly secure the wheelchair cushion directly contributed to the resident's fall during the transfer process.