Failure to Properly Restrain Resident During Transportation
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for all care and had significant mobility limitations due to central cord syndrome and bilateral lower extremity contractures, was not properly restrained during transportation in the facility van. The facility's transportation policy required that all residents be properly secured with seat belts and wheelchair restraints during transport, and that drivers be trained and competent in these procedures. On the day of the incident, the designated transportation driver, who was new to the role, failed to apply the seat belt to the resident's wheelchair, although the wheelchair was locked in place with hooks. During the transport, the driver had to stop suddenly at a red light, causing the resident to slide out of the wheelchair and fall forward onto the floor of the van, hitting the left side of the face/forehead on the back of the driver's seat. The resident reported not having a seat belt on and stated that this was the first time with this particular driver. The driver admitted to forgetting to apply the seat belt and was not fully aware of the seat belt procedure, as prior training had not included this step. The resident was assessed after the incident and did not report new pain or visible injury at the time, but later mentioned some pain around the eye without bruising or cuts. Interviews with facility staff confirmed that the transportation driver had not completed the required competency demonstration for securing residents prior to the incident. The driver had only been shown how to use the wheelchair hooks and was not instructed on the use of seat belts. The facility's policy and staff statements indicated that all residents should be properly restrained during transport, but this was not followed in this case, resulting in the resident's fall and injury during transportation.