Failure to Properly Secure Wheelchair-Bound Resident During Transport Results in Serious Injury
Penalty
Summary
A facility failed to ensure that a resident, who was dependent on staff for all aspects of care and utilized a wheelchair for mobility, was safely secured with a seat belt and properly positioned during transport on the facility bus. The resident had significant medical conditions, including left-sided hemiplegia and hemiparesis following a stroke, dysphagia, dysarthria, diabetes with polyneuropathy, generalized muscle weakness, and was on anticoagulation therapy with aspirin and Plavix. The resident was unable to ambulate or stand independently and required assistance for all activities of daily living. On the day of the incident, the transportation driver loaded the resident into a tilt-in-space wheelchair and positioned her facing the passenger side of the bus, tilted back for comfort. The driver did not secure the resident with a lap belt, stating that the seat belt was obstructed by the wheelchair's position and that the resident's upper body would not move. The wheelchair was secured to the bus using four-point hooks, but the resident herself was not restrained with the seat belt. During transport, a bolt on the wheelchair broke, causing the left arm of the wheelchair to bend and the resident to fall out of the chair onto the floor of the bus. The incident was unwitnessed, and the driver continued to drive to a nearby hospital after discovering the resident on the floor. Upon evaluation at the hospital, the resident was found to have sustained a subdural hematoma and subarachnoid hemorrhage, requiring admission to the intensive care unit. The investigation revealed that the driver had limited training and had not previously driven a transport bus, and that the resident was not secured according to the facility's bus safety manual and wheelchair restraint guidelines.