Failure to Secure Residents During Van Transport Results in Serious Injury
Penalty
Summary
The facility failed to ensure that two residents were properly secured in their wheelchairs during van transportation, resulting in one resident sustaining serious injuries. Specifically, one resident with multiple complex medical conditions, including chronic kidney disease, COPD, Parkinson's disease, and a history of falls, was being transported in a facility van when the driver abruptly braked, causing the resident to fall forward from the wheelchair and suffer fractures to the humerus, tibia, and fibula. The investigation revealed that the seatbelt did not properly lock in place, and the shoulder belt was broken and would not tighten. The lap belt was also missing from another seat, and these issues had been previously reported to facility administrators but were not addressed. Interviews and observations confirmed that the van's wheelchair securement system was malfunctioning, with missing and broken belts, and that the van should not have been in service. The maintenance director and a technician from the mobility company verified that the occupant securement system was not fully functioning, and the last inspection had occurred several months prior. Another resident in the van at the time was not injured but reported that neither the lap nor shoulder belt was in use. The failure to maintain the van's securement system and to ensure residents were properly secured directly led to the accident and resulting injuries.