Resident Injury During Van Transport Due to Inadequate Securing
Penalty
Summary
A deficiency occurred when a resident with chronic kidney disease, schizophrenia, seizures, altered mental status, muscle weakness, and mobility abnormalities was being transported by facility van to dialysis. The facility's policy required that wheelchair users be secured with four straps and a seat belt during transport. On the day of the incident, the resident was placed in the van, and the seat belt was applied by an LPN/charge nurse, while a CNA was responsible for driving and ensuring the resident was secured. During transport, the CNA observed the resident sliding out of the wheelchair via the rearview mirror. Upon stopping the van, the resident was found on the floor with a laceration to the right leg, requiring EMS transport to the emergency room and subsequent sutures. Review of documentation and staff interviews confirmed that the seat belt was still connected around the wheelchair after the incident, but the resident had nonetheless slid out of the chair. The facility's maintenance supervisor demonstrated the van's securing process and stated that, if the seat belt was placed correctly, the resident could not fall out. However, the incident report and staff statements indicated that the resident was not adequately secured, resulting in the accident and injury. The administrator acknowledged that the in-service training provided after the incident did not address the specific concern of the resident sliding out of the wheelchair during transport.