Failure to Properly Secure Wheelchair During Transport Results in Resident Injury
Penalty
Summary
A deficiency occurred when facility staff failed to follow the manufacturer's instructions for securing a wheelchair in the facility's transportation van. The Transport Driver incorrectly anchored all four securement straps to the rear wheels of the wheelchair, leaving the front of the wheelchair unsecured. According to the manufacturer's instructions, tie-down hooks should be attached to solid frame members near seat level and not to wheels, plastic, or removable parts. This improper anchoring allowed the wheelchair to tip backward during vehicle acceleration. The incident involved a resident with multiple medical conditions, including neuropathy, chronic ischemic heart disease, osteomyelitis, diabetes, and a left leg above-knee amputation. The resident was cognitively intact, dependent on staff for transfers, and required assistance with wheelchair mobility. During transport to a dental appointment, the resident's wheelchair tipped backward when the van accelerated from a stop, causing her to fall and strike her head and back on the floor of the van. The resident was wearing a seatbelt at the time of the incident. As a result of the fall, the resident experienced posterior neck and upper back pain, a superficial laceration on the tongue, paraspinal tenderness in the upper thoracic region, and a superficial abrasion on the right hand. She was transported to the hospital, where CT scans showed no evidence of hemorrhage or acute fracture, and she was discharged back to the facility later that evening. The investigation confirmed that the Transport Driver had attached both front and rear anchor straps to the rear wheels, leaving the wheelchair frame free to rotate and tip over during transport.
Removal Plan
- Resident #1's wheelchair tipped backwards in the facility transportation van due to the transportation driver failing to follow manufacturer's instructions for wheelchair securement. The driver had improperly anchored both left and right front and rear straps to the rear wheels, leaving the front of the wheelchair unsecured. When the vehicle accelerated, the wheelchair tipped backwards, causing Resident #1's head and back to strike the floor of the van. Emergency services were called, and Resident #1 was transported to the hospital where she was treated for posterior neck pain, upper back pain, a superficial tongue laceration, paraspinal tenderness, and a superficial abrasion to her right hand. A CT scan revealed no evidence of hemorrhage or acute fracture, and the resident was discharged back to the facility.
- The transportation driver was removed from driving duties pending retraining and competency validation.
- The facility conducted a 100% audit of progress notes, transport log and interview with the Transportation Driver of in-house facility residents' transports for the past 90 days by the Assistant Director of Nursing, with no concerns identified.
- The Assistant Director of Nursing reviewed the transport log to identify any resident that would potentially be transported with facility van. No residents were to be transported until investigation and retraining completed.
- All scheduled appointments were scheduled by the Transportation Driver with a contracted outside transportation company.
- The facility has two employees who drive the transportation van. The Transportation Driver is the primary driver and the Maintenance Director is the back up driver.
- The Administrator audited the transport employee files: audit to include training, valid driver's license, van maintenance checklist to include proper alignment of the wheelchair between the tie down straps, attaching the rear tie down straps to the rear frame, front tie down straps to the front frame, ensuring tightness on both the front and rear tie downs, and securing seatbelt around resident, and employee vehicle policy to include but not limited to vehicle purpose, driver licensing, maintenance of company van, proof of insurance on company van, traffic violations, usage of cellular phone, accidents involving company vehicle, theft of company vehicle and driver responsibilities in regards to operation of vehicle, use of seatbelts and securement devices and reporting requirements with no concerns identified.
- The Maintenance Director did the initial education for the Transportation Driver on site of incident and return demonstration.
- The Administrator reviewed the manufacturer's video and training documents provided by the facility and re-educated post incident.
- The Maintenance Director conducted education and an initial return demonstration with the Transportation Driver, Director of Nursing and Administrator that included proper securement of the wheelchair and van anchors per manufacturer's instructions.
- Outside Maintenance Director from a sister facility provided additional education to the Administrator, Maintenance Director and Transportation Driver regarding proper securement of the wheelchair and van anchors per manufacturer's instructions.
- The Administrator initiated 100% in-service with the Maintenance Director and Transportation Driver about proper securement of wheelchairs during transport per manufacturer's instructions. The in-service was completed.
- All newly hired Transport Drivers will be in-serviced by the Maintenance Director during orientation to include the skills check list. The skills check list includes but is not limited to a competency validation of loading, securing and unloading a resident and a return demonstration.
- The Maintenance Director sent the van out for inspection that included checking functional status of the wheelchair anchors with no concerns identified.
- The facility initiated 10% audit of all residents being transported by the facility to be completed by the Maintenance Director weekly then monthly utilizing the Van Transport Audit Tool to ensure proper securing of the resident before leaving the facility and this was taken to Quality Assurance committee meeting. This audit is an observational audit to determine proper securement of the resident, wheelchair, and van anchors. The results will be documented on the Van Transport Audit Tool. All areas of concern will be addressed by the Administrator and/or Maintenance Director immediately.
- The Administrator will forward the results of the Van Transport Audit Tool to the Executive Quality Assurance Committee to include Administrator, Director of Nursing, Assistant Director of Nursing, Quality Assurance Nurse, Infection Control Preventionist/Staff Development Nurse, Activities Director, social workers, unit managers and unit coordinators, Maintenance Director, Minimum Data Set nurse, Dietary Manager, Medical Director and additional staff representatives monthly for review to determine trends and / or issues that may need further interventions put into place and to determine the need for further and / or frequency of monitoring.