Failure to Provide Safe Transport and Adequate Supervision During Resident Van Transfer
Penalty
Summary
A deficiency occurred when a resident, who required substantial to maximal assistance for mobility and transfers and had intact cognition, was transported to an outside appointment in a facility van while seated in her wheelchair. The resident's wheelchair was secured using tie-downs, but no seatbelt or safety belt was provided, as the facility did not have a device that would fit her wheelchair. Both the CNA and the activity aide responsible for the transport were aware that no protective device was available to secure the resident during the trip. During the transport, the van encountered a bump in a construction zone, causing the resident to slide partially out of her wheelchair and strike her left knee against the back of the seat in front of her. The resident immediately complained of pain, and upon return to the facility, further assessment and x-rays revealed a fractured left femur. The resident required hospitalization and surgical repair for the injury. Interviews and documentation confirmed that the staff did not provide a seatbelt or other safety restraint for the resident during transport, despite facility policy requiring residents to be secured with a seatbelt or wheelchair seat belt. The facility was unable to provide documentation of staff training on safe transport procedures, and the investigation found that the resident's wheelchair was not rated for use in the van and could not be safely secured with available equipment.