Failure to Follow Wheelchair Lift Safety Protocols Results in Resident Injury
Penalty
Summary
A deficiency occurred when facility staff failed to follow the manufacturer's safety guidelines for operating a wheelchair lift, resulting in a resident falling from the facility transport bus and sustaining a head laceration that required emergency department treatment. The incident took place as the resident, who had a history of falls, impaired mobility, and required staff assistance for activities of daily living, was being loaded onto the bus by a staff member trained to operate the lift. The resident was dependent on staff for self-care, used a manual wheelchair, and had cognitive capacity but exhibited anxiety and behavioral symptoms on the day of the incident. During the transfer, the staff member backed the resident's wheelchair onto the lift, locked the brakes, and began raising the lift. The lift stopped unexpectedly about six inches from the ground. The staff member, while attempting to determine the cause of the stoppage, stepped off the lift, leaving the resident unattended. At this point, the resident's wheelchair rolled forward, and the resident fell off the lift, hitting her head on the ground. The investigation revealed that the front wheels of the wheelchair were not properly positioned behind the yellow foot stop, and the resident was not secured with a seatbelt or torso restraint. Additionally, the staff member did not instruct the resident to hold onto the handrails, and the wheelchair brakes were not fully engaged. Further review found that the facility did not have the owner's manual for the lift on hand, and staff training documentation was incomplete, with skills validation checklists lacking proper markings or evaluations. The facility's policy required staff to be trained in the use of wheelchair lifts and to ensure proper securement of residents during transport, including the use of occupant restraints. However, these procedures were not followed, directly contributing to the resident's fall and injury.