Failure to Properly Secure Wheelchair During Transport Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a facility failed to properly secure a resident's wheelchair during transport in the facility van. The resident, who had diagnoses including COPD, atrial fibrillation, rheumatoid arthritis, and hypertension, and who required a wheelchair for mobility, was being transported by a staff member. During the trip, the staff member made a right turn, after which the resident's wheelchair tipped to the left side of the van. The wheelchair did not completely overturn, but the resident sustained a skin tear to the left forearm and reported possibly hitting the back of her head. The resident was subsequently sent to the emergency room for evaluation and treatment. Upon assessment, the resident was found to have significant bruising on various parts of the body and a skin avulsion on the left forearm. The resident was on anticoagulant therapy, which may have contributed to the extent of bruising. The resident was alert and oriented, and denied loss of consciousness or other major symptoms, but did report some back pain from sitting on the floor of the van after the incident. The staff member involved stated that she believed she had secured the wheelchair properly, but later realized she had not followed the correct procedure for attaching the restraint straps, having woven them through the wheels instead of attaching them to the wheelchair frame as required. Interviews and record reviews revealed that the staff member had not been properly trained on the correct method for securing wheelchairs in the van. The facility's policy required that all residents and wheelchairs be safely secured during transport, but this was not adhered to in this instance. The incident resulted in injury to the resident and demonstrated a failure to ensure the area was free from accident hazards and that adequate supervision and training were provided to prevent such accidents.