Failure to Ensure Safe Use of Wheelchair Lift During Resident Transport
Penalty
Summary
A deficiency occurred when a facility failed to ensure a resident environment free from accident hazards and did not provide adequate supervision to prevent accidents for one resident. The incident involved a female resident with end stage renal disease, diabetes mellitus, heart failure, and mild cognitive impairment, who was mobile via wheelchair and required regular dialysis treatments. On the day of the incident, the resident was being transported to a dialysis center in the facility's van. During the unloading process, the van driver lowered the wheelchair lift to the ground but became distracted by a bag left by another resident. The driver then re-entered the van, unlatched the resident, and began backing her in her wheelchair out of the van, unaware that the lift was not flush with the van floor. As a result, both the resident and the van driver fell out of the van, landing on the lift platform positioned on the ground. The resident sustained a scratch to her finger and complained of a headache, but declined to go to the emergency room. X-rays and neuro checks performed later showed no injuries. The facility's records indicated that the van and lift were operating correctly at the time of the incident. The van driver had received training on the operation of the van and lift, as well as on abuse and neglect, prior to the event. However, the driver failed to follow established procedures for ensuring the lift was in the correct position before unloading the resident, which directly led to the fall. The incident was documented in progress notes, and statements from the resident, van driver, and facility staff confirmed the sequence of events that resulted in the deficiency.