Improper Wheelchair Securement During Transportation Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident's wheelchair was not properly secured during transportation in the facility van, resulting in the wheelchair tipping over. The incident led to the resident sustaining a skin tear to the elbow and an abrasion to the head, requiring evaluation and treatment at an emergency room. The resident had multiple medical diagnoses, including a stage 4 pressure ulcer, chronic respiratory failure, chronic pain, atherosclerotic heart disease, coronary artery disease, and anxiety. The facility's investigation revealed that, although the employee responsible for securing the wheelchair had been previously validated as competent, the wheelchair was not installed according to the manufacturer's instructions. Specifically, the emergency release lever for the floor securement system was accessible to the resident and could be engaged accidentally. During the incident, three of the four floor safety restraints remained secured, but the left front restraint was found to be loosened, which allowed the wheelchair to tip over when the vehicle turned a corner. Further review and interviews with the manufacturer confirmed that the emergency release lever should not have been accessible to the resident and that the straps should have been positioned at a 45-degree angle to prevent accidental engagement. The improper installation of the wheelchair securement system directly contributed to the loosening of the restraint and the subsequent accident.